Provider Demographics
NPI:1518588854
Name:BENNETT, KRISTIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 N PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-4528
Mailing Address - Country:US
Mailing Address - Phone:229-469-6932
Mailing Address - Fax:
Practice Address - Street 1:1701 BOULEVARD SQ STE F
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8022
Practice Address - Country:US
Practice Address - Phone:229-469-6932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist