Provider Demographics
NPI:1366222911
Name:STURDIVAN, KRISTIN MARIE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:STURDIVAN
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:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-1147
Mailing Address - Country:US
Mailing Address - Phone:253-880-4938
Mailing Address - Fax:
Practice Address - Street 1:110 2ND ST SW STE 110
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-5250
Practice Address - Country:US
Practice Address - Phone:253-237-3405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI6190968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist