Provider Demographics
NPI:1568682672
Name:BROWN, CRISTAL GORDON (SLP)
Entity Type:Individual
Prefix:MS
First Name:CRISTAL
Middle Name:GORDON
Last Name:BROWN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 FOREST PARK AVE
Mailing Address - Street 2:CB 8502
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2212
Mailing Address - Country:US
Mailing Address - Phone:314-286-1940
Mailing Address - Fax:314-286-1473
Practice Address - Street 1:4240 DUNCAN AVE
Practice Address - Street 2:DEPT PHYSICAL THERAPY, STE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1101
Practice Address - Country:US
Practice Address - Phone:314-286-1940
Practice Address - Fax:314-286-1473
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002001247235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO465744126Medicaid