Provider Demographics
NPI:1659661221
Name:TISON, KATHRYN CLAIRE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLAIRE
Last Name:TISON
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 1:369 93RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6901
Mailing Address - Country:US
Mailing Address - Phone:929-275-3119
Mailing Address - Fax:
Practice Address - Street 1:369 93RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-6901
Practice Address - Country:US
Practice Address - Phone:929-275-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017443-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist