Provider Demographics
NPI:1144713108
Name:MARCONI, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MARCONI
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 1:2512 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-3635
Mailing Address - Country:US
Mailing Address - Phone:248-733-4325
Mailing Address - Fax:
Practice Address - Street 1:2512 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-3635
Practice Address - Country:US
Practice Address - Phone:248-733-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist