Provider Demographics
NPI:1013224450
Name:PARK, KRYSTAL BLAIR
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:BLAIR
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 MCKINNEY AVE
Mailing Address - Street 2:#233
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-8603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2808 MCKINNEY AVE
Practice Address - Street 2:#233
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-8603
Practice Address - Country:US
Practice Address - Phone:214-686-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist