Provider Demographics
NPI:1659401271
Name:CRISTAL, MAUREEN ANN
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ANN
Last Name:CRISTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BARBADOS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606
Mailing Address - Country:US
Mailing Address - Phone:813-250-9121
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884135700Medicaid