Provider Demographics
NPI:1104014109
Name:WOODLAND, CRISTY (MS, SLP INTERN)
Entity Type:Individual
Prefix:
First Name:CRISTY
Middle Name:
Last Name:WOODLAND
Suffix:
Gender:F
Credentials:MS, SLP INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S PONSARD ST
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-2164
Mailing Address - Country:US
Mailing Address - Phone:936-465-6194
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST STE 1204
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5700
Practice Address - Country:US
Practice Address - Phone:903-509-2040
Practice Address - Fax:855-587-4499
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342042355S0801X
TX118080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant