Provider Demographics
NPI:1992030159
Name:DELUCA, KRISTEN E
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:E
Last Name:DELUCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 VENETIAN DR
Mailing Address - Street 2:UNIT 105
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-8480
Mailing Address - Country:US
Mailing Address - Phone:631-495-9695
Mailing Address - Fax:321-327-4496
Practice Address - Street 1:1065 VENETIAN DR
Practice Address - Street 2:UNIT 105
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-8480
Practice Address - Country:US
Practice Address - Phone:631-495-9695
Practice Address - Fax:321-327-4496
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist