Provider Demographics
NPI:1780857342
Name:AMIDON, KIRSTIN M (MA-CCC)
Entity Type:Individual
Prefix:MS
First Name:KIRSTIN
Middle Name:M
Last Name:AMIDON
Suffix:
Gender:F
Credentials:MA-CCC
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:M
Other - Last Name:HUSEBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA-CCC
Mailing Address - Street 1:711 PRUITT DR
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-5318
Mailing Address - Country:US
Mailing Address - Phone:310-701-0120
Mailing Address - Fax:
Practice Address - Street 1:711 PRUITT DR
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-5318
Practice Address - Country:US
Practice Address - Phone:310-701-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist