Provider Demographics
NPI:1629327382
Name:FAHNSTROM, KRISTEN FAITH (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:FAITH
Last Name:FAHNSTROM
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:FAITH
Other - Last Name:MACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:661 CAMBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 WESTBROOK CORPORATE CTR STE 800
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5702
Practice Address - Country:US
Practice Address - Phone:800-714-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-09
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
IL146011275235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist