Provider Demographics
NPI:1649434960
Name:VICTORINO, KRISTEN (PHD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:VICTORINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:RUSSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1112 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2906
Mailing Address - Country:US
Mailing Address - Phone:646-734-6381
Mailing Address - Fax:
Practice Address - Street 1:1112 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2906
Practice Address - Country:US
Practice Address - Phone:646-734-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00569300235Z00000X
NY011911-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist