Healthcare Provider Details

I. General information

NPI: 1932166097
Provider Name (Legal Business Name): KRISTEN MARIE BENCOMO MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 S ALAFAYA TRL SUITE 101
ORLANDO FL
32828-8926
US

IV. Provider business mailing address

831 RIVECON AVE
ORLANDO FL
32825-7323
US

V. Phone/Fax

Practice location:
  • Phone: 321-303-4569
  • Fax: 407-382-5637
Mailing address:
  • Phone: 321-303-4569
  • Fax: 407-382-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ 3383
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: