Provider Demographics
NPI:1629370853
Name:GAMBRELL, KRYSTAL S (SLP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:S
Last Name:GAMBRELL
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 1:842 N HIGHLAND AVE NE
Mailing Address - Street 2:SUITE 275
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4530
Mailing Address - Country:US
Mailing Address - Phone:404-575-4000
Mailing Address - Fax:404-575-4010
Practice Address - Street 1:4075 DEMOONEY RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-1312
Practice Address - Country:US
Practice Address - Phone:404-520-0087
Practice Address - Fax:833-569-5677
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist