Provider Demographics
NPI:1548579287
Name:DAVIS, CRYSTAL I (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:I
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:I
Other - Last Name:FAUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:633 W SOUTHERN AVE
Mailing Address - Street 2:UNIT 1129
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-4546
Mailing Address - Country:US
Mailing Address - Phone:303-709-8870
Mailing Address - Fax:
Practice Address - Street 1:10049 E DYNAMITE BLVD
Practice Address - Street 2:STE. 110
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-3694
Practice Address - Country:US
Practice Address - Phone:480-419-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP6965235Z00000X
AZSLP6965235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist