Provider Demographics
NPI:1538351507
Name:DAVIS-KRISSMAN, ANDREA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:DAVIS-KRISSMAN
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 1:34 FONTAINE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72830-3928
Mailing Address - Country:US
Mailing Address - Phone:870-642-6449
Mailing Address - Fax:
Practice Address - Street 1:34 FONTAINE DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3928
Practice Address - Country:US
Practice Address - Phone:479-647-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142879721Medicaid