Provider Demographics
NPI:1467475533
Name:KNUDSEN, CHRISTINE MARIE (ST)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:MISS
Other - First Name:CHRISTINE
Other - Middle Name:MARIE
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ST
Mailing Address - Street 1:4645 BELPAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3602
Mailing Address - Country:US
Mailing Address - Phone:330-493-4210
Mailing Address - Fax:330-493-4744
Practice Address - Street 1:2821 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-6215
Practice Address - Country:US
Practice Address - Phone:330-478-1752
Practice Address - Fax:330-478-1763
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 8073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000335879OtherANTHEM BC/BS