1518096833 NPI number — MS. BETHANY MARIE KISNER-CROSBY MA-SLP-CCC-L

Table of content: MS. BETHANY MARIE KISNER-CROSBY MA-SLP-CCC-L (NPI 1518096833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518096833 NPI number — MS. BETHANY MARIE KISNER-CROSBY MA-SLP-CCC-L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KISNER-CROSBY
Provider First Name:
BETHANY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA-SLP-CCC-L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518096833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
247 TILTON PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEKALB
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60115-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-739-1452
Provider Business Mailing Address Fax Number:
815-756-5359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
247 TILTON PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEKALB
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60115-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-739-1452
Provider Business Practice Location Address Fax Number:
815-756-5359
Provider Enumeration Date:
03/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146005808 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01926198 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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