Provider Demographics
NPI:1811401409
Name:COLLINS, KRYSTAL ALEXANDRA
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ALEXANDRA
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:TALARICO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:135 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-4236
Mailing Address - Country:US
Mailing Address - Phone:203-561-4615
Mailing Address - Fax:
Practice Address - Street 1:135 RIVER ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-4236
Practice Address - Country:US
Practice Address - Phone:203-561-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist