Basic Information
Provider Information | |||||||||
NPI: | 1376059055 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRAIN | ||||||||
FirstName: | CRISTEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FUDGE | ||||||||
OtherFirstName: | CRISTEL | ||||||||
OtherMiddleName: | JO-EL | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1326 CHURCH ST | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 707912743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256548208 | ||||||||
FaxNumber: | 2256544642 | ||||||||
Practice Location | |||||||||
Address1: | 1326 CHURCH ST | ||||||||
Address2: |   | ||||||||
City: | ZACHARY | ||||||||
State: | LA | ||||||||
PostalCode: | 70791 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256548208 | ||||||||
FaxNumber: | 2256544642 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2017 | ||||||||
LastUpdateDate: | 08/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3824 | LA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 3824 | 01 | LA | SPEECH LICENSE | OTHER | 005579086 | 01 | LA | LICENSE | OTHER |