Provider Demographics
NPI:1477636074
Name:LONGSTREET, KARYN ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KARYN
Middle Name:ANN
Last Name:LONGSTREET
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3068
Mailing Address - Country:US
Mailing Address - Phone:307-638-9769
Mailing Address - Fax:307-632-3481
Practice Address - Street 1:523 W 27TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3068
Practice Address - Country:US
Practice Address - Phone:307-638-9769
Practice Address - Fax:307-632-3481
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-311235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114827300Medicaid