Provider Demographics
NPI:1366205387
Name:BANDONG, KIRSTIANA (CCC SLP)
Entity type:Individual
Prefix:
First Name:KIRSTIANA
Middle Name:
Last Name:BANDONG
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 1:2765 MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-1601
Mailing Address - Country:US
Mailing Address - Phone:510-358-1881
Mailing Address - Fax:
Practice Address - Street 1:2765 MITCHELL DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-1601
Practice Address - Country:US
Practice Address - Phone:510-358-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist