Provider Demographics
NPI:1801157961
Name:YOUNG, KRISTINE (SLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:YOUNG
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 1:3400 LAKESIDE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041-2448
Mailing Address - Country:US
Mailing Address - Phone:714-743-0414
Mailing Address - Fax:
Practice Address - Street 1:4922 LASALLE RD
Practice Address - Street 2:BUILDING-B
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3302
Practice Address - Country:US
Practice Address - Phone:301-864-2333
Practice Address - Fax:877-828-2060
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06581235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD46-3684374OtherTAX ID
MD4374045-00Medicaid
MD1447657507OtherNPI TYPE 2 (ORGANIZATION NPI)
MD4374045-00Medicaid
MD46-3684374OtherTAX ID