Provider Demographics
NPI:1639672728
Name:BLACK, KRISTEN ALICE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ALICE
Last Name:BLACK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ELENA CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9175
Mailing Address - Country:US
Mailing Address - Phone:609-760-3921
Mailing Address - Fax:
Practice Address - Street 1:21585 PEABODY ST
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2955
Practice Address - Country:US
Practice Address - Phone:301-475-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist