Provider Demographics
NPI:1821507641
Name:WATANABE, KRISTIN KIYOMI (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KIYOMI
Last Name:WATANABE
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 S MANHATTAN PL
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 HAMNER AVE STE 107
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-2673
Practice Address - Country:US
Practice Address - Phone:310-528-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPE11449235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist