MEDICARE: KRISTEN CANTRELL MA, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP. 10575	OH

General Provider Information

NPI Number	:	1902346604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN CANTRELL MA, CCC-SLP

Provider Business Mailing Address
First Line	:	1 AVALON RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-1403
Country	:	US
Telephone Number	:	740-358-0007
Fax Number	:	740-470-1076

Provider Business Practice Location Address
First Line	:	1 AVALON RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-1403
Country	:	US
Telephone Number	:	440-725-3948
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	07/05/2022

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