Provider Demographics
NPI:1497278188
Name:MADAK, KRISZTINA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KRISZTINA
Middle Name:
Last Name:MADAK
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 1:11874 ROCIO ST APT 1804
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-9047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 RIVER HALL PKWY
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:FL
Practice Address - Zip Code:33920-4601
Practice Address - Country:US
Practice Address - Phone:239-693-0349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14624235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist