Basic Information
| Provider Information | |||||||||
| NPI: | 1497190037 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENZI | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2013 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22005971A | IN | N | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 46002440A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.