Provider Demographics
NPI:1730865726
Name:FENTON, KRISTYNE MICHELLE (SLP)
Entity type:Individual
Prefix:
First Name:KRISTYNE
Middle Name:MICHELLE
Last Name:FENTON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 SUMMERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5611
Mailing Address - Country:US
Mailing Address - Phone:516-859-5486
Mailing Address - Fax:
Practice Address - Street 1:101 LOUDEN AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2736
Practice Address - Country:US
Practice Address - Phone:631-608-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist