Provider Demographics
NPI:1730271396
Name:GUSTAFSON-RAIRIE, KRISTINA (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:
Last Name:GUSTAFSON-RAIRIE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OKLAHOMA ST.
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:43365
Mailing Address - Country:US
Mailing Address - Phone:352-746-9448
Mailing Address - Fax:352-746-9323
Practice Address - Street 1:130 HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4571
Practice Address - Country:US
Practice Address - Phone:352-746-9233
Practice Address - Fax:352-746-9323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 5386235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886615500Medicaid
FLS2526OtherBLUE CROSS