Provider Demographics
NPI:1760070262
Name:WALLACE, KRISTIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:WALLACE
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 1:8325 LOTT RD
Mailing Address - Street 2:
Mailing Address - City:WILMER
Mailing Address - State:AL
Mailing Address - Zip Code:36587-9559
Mailing Address - Country:US
Mailing Address - Phone:251-401-6265
Mailing Address - Fax:
Practice Address - Street 1:8325 LOTT RD
Practice Address - Street 2:
Practice Address - City:WILMER
Practice Address - State:AL
Practice Address - Zip Code:36587-9559
Practice Address - Country:US
Practice Address - Phone:251-401-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4356235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist