Provider Demographics
NPI:1457677783
Name:CRYSTAL ACADEMY
Entity Type:Organization
Organization Name:CRYSTAL ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-447-2332
Mailing Address - Street 1:110 PHOENETIA AVE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-3312
Mailing Address - Country:US
Mailing Address - Phone:305-567-5881
Mailing Address - Fax:395-567-5882
Practice Address - Street 1:110 PHOENETIA AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-3312
Practice Address - Country:US
Practice Address - Phone:305-567-5881
Practice Address - Fax:395-567-5882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty