Provider Demographics
NPI:1447475835
Name:WILLEY, KRISTEN ELAINE
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ELAINE
Last Name:WILLEY
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 1:42 WENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-3271
Mailing Address - Country:US
Mailing Address - Phone:410-603-5830
Mailing Address - Fax:
Practice Address - Street 1:42 WENTWOOD DR
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3271
Practice Address - Country:US
Practice Address - Phone:410-603-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist