=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518096833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY MARIE KISNER-CROSBY MA-SLP-CCC-L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2007
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 TILTON PARK DR
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-739-1452
-----------------------------------------------------
Fax | 815-756-5359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 TILTON PARK DR
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-1955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-739-1452
-----------------------------------------------------
Fax | 815-756-5359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146005808
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------