Provider Demographics
NPI:1114164886
Name:MACDONALD, CRYSTAL A
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:A
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795
Mailing Address - Country:US
Mailing Address - Phone:860-945-3012
Mailing Address - Fax:860-945-9854
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06779-1999
Practice Address - Country:US
Practice Address - Phone:860-945-3012
Practice Address - Fax:860-945-9854
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist