Provider Demographics
NPI:1518377084
Name:SMIRCICH, KRISTINE THERESA (SP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:THERESA
Last Name:SMIRCICH
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:THERESA
Other - Last Name:BLOUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SP
Mailing Address - Street 1:1200 B GALE WILSON BLVD
Mailing Address - Street 2:ATTN REHAB DEPT
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3552
Mailing Address - Country:US
Mailing Address - Phone:707-646-4150
Mailing Address - Fax:
Practice Address - Street 1:1101 B GALE WILSON BLVD
Practice Address - Street 2:SUITE 101A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3700
Practice Address - Country:US
Practice Address - Phone:707-646-4150
Practice Address - Fax:707-646-4153
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9686235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist