Provider Demographics
NPI:1033566872
Name:ROMAN, CRYSTAL (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13517 HARTLE GROVES PL APT 209
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8757
Mailing Address - Country:US
Mailing Address - Phone:407-451-7028
Mailing Address - Fax:
Practice Address - Street 1:606 SHERBURN CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9017
Practice Address - Country:US
Practice Address - Phone:407-883-8636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ7535235Z00000X
FLSA15414235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist