Provider Demographics
NPI:1790990885
Name:THOMASON, CRYSTAL NICHOLE (MED CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:NICHOLE
Last Name:THOMASON
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 1:11 CEDAR RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-460-1555
Mailing Address - Fax:
Practice Address - Street 1:105 ANY WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4198
Practice Address - Country:US
Practice Address - Phone:229-460-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103124235Z00000X
GASLP006390235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist