Provider Demographics
NPI:1932565587
Name:TOLLETT, KIRSTIE DANIELLE (SLPA)
Entity Type:Individual
Prefix:MISS
First Name:KIRSTIE
Middle Name:DANIELLE
Last Name:TOLLETT
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N HILL ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-2961
Mailing Address - Country:US
Mailing Address - Phone:870-784-1421
Mailing Address - Fax:
Practice Address - Street 1:106 N HILL ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-2961
Practice Address - Country:US
Practice Address - Phone:870-784-1421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR#15-0192355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211271721Medicaid