Provider Demographics
NPI:1164890679
Name:DITZIG, KRYSTAL MARIE (CF-SLP)
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:MARIE
Last Name:DITZIG
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 SPRINGFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-9227
Mailing Address - Country:US
Mailing Address - Phone:570-290-5654
Mailing Address - Fax:
Practice Address - Street 1:800 HAUSMAN RD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9393
Practice Address - Country:US
Practice Address - Phone:610-398-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
PASL012967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist