Healthcare Provider Details

I. General information

NPI: 1053445718
Provider Name (Legal Business Name): KRISTIN KUDARAUSKAS M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8723 LAROQUE RUN DR
FREDERICKSBURG VA
22407-1991
US

IV. Provider business mailing address

8723 LAROQUE RUN DR
FREDERICKSBURG VA
22407-1991
US

V. Phone/Fax

Practice location:
  • Phone: 540-693-0322
  • Fax:
Mailing address:
  • Phone: 540-693-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number05696
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202005451
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: