Provider Demographics
NPI:1790721835
Name:WEBBER, CRYSTAL MARIE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:WEBBER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 KEN HOLYOAK RD
Mailing Address - Street 2:
Mailing Address - City:ALAPAHA
Mailing Address - State:GA
Mailing Address - Zip Code:31622-2224
Mailing Address - Country:US
Mailing Address - Phone:229-686-0847
Mailing Address - Fax:229-532-3926
Practice Address - Street 1:430 KEN HOLYOAK RD
Practice Address - Street 2:
Practice Address - City:ALAPAHA
Practice Address - State:GA
Practice Address - Zip Code:31622-2224
Practice Address - Country:US
Practice Address - Phone:229-686-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA703655185DMedicaid
GA11-6850Medicare ID - Type UnspecifiedMEDICARE GP PROVIDER NUMB