Provider Demographics
NPI:1750611026
Name:WEITZ, KRISTEN PENROSE (MED)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:PENROSE
Last Name:WEITZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:MICHELLE
Other - Last Name:PENROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:970 CALLE AMANECER
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6250
Mailing Address - Country:US
Mailing Address - Phone:949-498-5100
Mailing Address - Fax:
Practice Address - Street 1:970 CALLE AMANECER
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP17715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist