Provider Demographics
NPI:1912338989
Name:MIESNER, KRISTIN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MIESNER
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-1610
Mailing Address - Country:US
Mailing Address - Phone:618-973-9328
Mailing Address - Fax:
Practice Address - Street 1:115 PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1610
Practice Address - Country:US
Practice Address - Phone:618-973-9328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist