=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528265121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN MARIE TESKE M.A. CCC SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1023 W MAIN ST
-----------------------------------------------------
City | VEVAY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47043-9192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-427-2803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 QUAIL RIDGE CT
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47250-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-571-0117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2200433A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------