Provider Demographics
NPI:1952032930
Name:WOODBURY, KRISTEN MILLER (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MILLER
Last Name:WOODBURY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 JUNIPER CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-6183
Mailing Address - Country:US
Mailing Address - Phone:801-380-1454
Mailing Address - Fax:
Practice Address - Street 1:410 JUNIPER CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-6183
Practice Address - Country:US
Practice Address - Phone:801-380-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010912235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist