Provider Demographics
NPI:1598047573
Name:KOGUT, TRISTA BAXTER (MS)
Entity Type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:BAXTER
Last Name:KOGUT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5992 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-1554
Mailing Address - Country:US
Mailing Address - Phone:315-559-5409
Mailing Address - Fax:
Practice Address - Street 1:8115 GATEHOUSE RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1203
Practice Address - Country:US
Practice Address - Phone:571-423-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017097235Z00000X
VA2202009350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist