Provider Demographics
NPI:1134961113
Name:PERRY, KIERSTAN
Entity type:Individual
Prefix:
First Name:KIERSTAN
Middle Name:
Last Name:PERRY
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 1:552 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4728
Mailing Address - Country:US
Mailing Address - Phone:504-708-2057
Mailing Address - Fax:
Practice Address - Street 1:1650 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4747
Practice Address - Country:US
Practice Address - Phone:505-984-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246Q00000X
NMSAH-2024-0176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology