Provider Demographics
NPI:1669731279
Name:MARDIS, KRISTEN LEIGH (SLP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:MARDIS
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 1:2015 FRANCES PL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2707
Mailing Address - Country:US
Mailing Address - Phone:318-614-7549
Mailing Address - Fax:
Practice Address - Street 1:2401 OLIVER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2934
Practice Address - Country:US
Practice Address - Phone:318-381-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist