Provider Demographics
NPI:1881906915
Name:RODRIGUES, KRISTEN LENA' (CCC-SLP, TSSLD)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LENA'
Last Name:RODRIGUES
Suffix:
Gender:F
Credentials:CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 KING ROAD
Mailing Address - Street 2:
Mailing Address - City:KING PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-3020
Mailing Address - Country:US
Mailing Address - Phone:631-406-7002
Mailing Address - Fax:
Practice Address - Street 1:380 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1845
Practice Address - Country:US
Practice Address - Phone:516-378-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235Z00000X
NY020413-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03847532Medicaid