Provider Demographics
NPI:1366579435
Name:LONG, KRISTEN SAMARA (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:SAMARA
Last Name:LONG
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8424 W MYSTIC LAKES SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MAIZE
Mailing Address - State:KS
Mailing Address - Zip Code:67101-8602
Mailing Address - Country:US
Mailing Address - Phone:316-722-7565
Mailing Address - Fax:
Practice Address - Street 1:621 W 21ST ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-8498
Practice Address - Country:US
Practice Address - Phone:316-733-1349
Practice Address - Fax:316-733-5883
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist