Provider Demographics
NPI:1871915462
Name:FREEBORN, KRISTINA ALYCIA (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:ALYCIA
Last Name:FREEBORN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:KRISTINA
Other - Middle Name:ALYCIA
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18550 144TH ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OK
Mailing Address - Zip Code:73051-6803
Mailing Address - Country:US
Mailing Address - Phone:405-609-4618
Mailing Address - Fax:405-310-0679
Practice Address - Street 1:120 S LESTER LANE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-5451
Practice Address - Country:US
Practice Address - Phone:405-766-1238
Practice Address - Fax:405-310-0679
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13641235Z00000X
CA19013235Z00000X
NVSP3377235Z00000X
FLTPSA160235Z00000X
GA011976235Z00000X
TX119383235Z00000X
OK4171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200954240AMedicaid