Provider Demographics
NPI:1235812843
Name:ANDERSON, CRYSTAL NICHOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICHOLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 DIVIDING RIDGE RD N
Mailing Address - Street 2:
Mailing Address - City:SADIEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40370-9615
Mailing Address - Country:US
Mailing Address - Phone:859-333-0289
Mailing Address - Fax:
Practice Address - Street 1:2770 PALUMBO DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1232
Practice Address - Country:US
Practice Address - Phone:859-263-2410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY14147643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist