Provider Demographics
NPI:1730624685
Name:RISBERG, KAITLYN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:RISBERG
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 1:211 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4517
Mailing Address - Country:US
Mailing Address - Phone:631-943-0752
Mailing Address - Fax:
Practice Address - Street 1:121 6TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1510
Practice Address - Country:US
Practice Address - Phone:212-453-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9944235Z00000X
NY027076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist