Provider Demographics
NPI:1548397144
Name:ANGELICA, KRISTEN COLLEEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:COLLEEN
Last Name:ANGELICA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3436 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-660-2450
Practice Address - Fax:323-667-1283
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 11508235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist