Basic Information
| Provider Information | |||||||||
| NPI: | 1124281142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDEHN | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | ROWAN-CLAIRE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | UDEHN | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 28780 SINGLE OAK DR | ||||||||
| Address2: | STE. 290 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925903625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516935871 | ||||||||
| FaxNumber: | 9516935872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 13478 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 0237659 | 01 | WA | STATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES | OTHER | SP0134780 | 01 | CA | BLUE SHIELD | OTHER |