Provider Demographics
NPI:1780939827
Name:MACINNIS, KRISTIN A
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:MACINNIS
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 1:23 WENTWORTH RD
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901-2831
Mailing Address - Country:US
Mailing Address - Phone:603-548-6661
Mailing Address - Fax:
Practice Address - Street 1:750 CENTRAL AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3434
Practice Address - Country:US
Practice Address - Phone:603-926-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist