Provider Demographics
NPI:1598016040
Name:SWAN, KRISTIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 STOCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-4232
Mailing Address - Country:US
Mailing Address - Phone:617-953-3399
Mailing Address - Fax:
Practice Address - Street 1:88 STOCKBRIDGE RD
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-4232
Practice Address - Country:US
Practice Address - Phone:617-953-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA12028926OtherASHA
MA5533OtherMA LICENSE