Provider Demographics
NPI:1861049629
Name:KIST, MATTHEW JOSEPH (AUD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:KIST
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 ERLANGER RD
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-1427
Mailing Address - Country:US
Mailing Address - Phone:859-342-5846
Mailing Address - Fax:859-342-4979
Practice Address - Street 1:463 ERLANGER RD
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-1427
Practice Address - Country:US
Practice Address - Phone:859-342-5846
Practice Address - Fax:859-342-4979
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA.02221231H00000X
KY247998231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist