Basic Information
| Provider Information | |||||||||
| NPI: | 1457677783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 PHOENETIA AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331343312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055675881 | ||||||||
| FaxNumber: | 3955675882 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 PHOENETIA AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331343312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055675881 | ||||||||
| FaxNumber: | 3955675882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 04/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | PIKE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3054472332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.