Provider Demographics
NPI:1013324771
Name:QUINN, KRISTA MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MICHELLE
Last Name:QUINN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MRS
Other - First Name:KRISTA
Other - Middle Name:MICHELLE
Other - Last Name:DOTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0725
Mailing Address - Country:US
Mailing Address - Phone:210-357-0395
Mailing Address - Fax:830-709-5493
Practice Address - Street 1:19965 FM 3175
Practice Address - Street 2:
Practice Address - City:LYTLE
Practice Address - State:TX
Practice Address - Zip Code:78052-3481
Practice Address - Country:US
Practice Address - Phone:210-357-0395
Practice Address - Fax:830-709-5493
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110326235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110326OtherPROFESSIONAL LICENSE- SPEECH LANGUAGE PATHOLOGIST