Provider Demographics
NPI:1518096833
Name:KISNER-CROSBY, BETHANY MARIE (MA-SLP-CCC-L)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:MARIE
Last Name:KISNER-CROSBY
Suffix:
Gender:F
Credentials:MA-SLP-CCC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 TILTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1955
Mailing Address - Country:US
Mailing Address - Phone:815-739-1452
Mailing Address - Fax:815-756-5359
Practice Address - Street 1:247 TILTON PARK DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1955
Practice Address - Country:US
Practice Address - Phone:815-739-1452
Practice Address - Fax:815-756-5359
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005808235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01926198OtherBCBS