Provider Demographics
NPI:1568677631
Name:SMIDT, KRISTIN SUZANNE (MASTERS OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SUZANNE
Last Name:SMIDT
Suffix:
Gender:F
Credentials:MASTERS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21334 N 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6422
Mailing Address - Country:US
Mailing Address - Phone:623-266-1004
Mailing Address - Fax:
Practice Address - Street 1:21334 N 64TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6422
Practice Address - Country:US
Practice Address - Phone:623-266-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1557235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist