Provider Demographics
NPI:1497959472
Name:HENDERSON, KRISTIN JANE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JANE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JANE HENDERSON
Other - Last Name:MONDOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:6508 GUNN HIGHWAY
Mailing Address - Street 2:INDEPENDENT LIVING INC
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-4022
Mailing Address - Country:US
Mailing Address - Phone:813-963-6923
Mailing Address - Fax:813-264-0768
Practice Address - Street 1:6508 GUNN HIGHWAY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-963-6923
Practice Address - Fax:813-264-0768
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL52766OtherBCBS