Provider Demographics
NPI:1821109091
Name:BROOKS, CRYSTAL K (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:K
Last Name:BROOKS
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 1:616 INDIAN WELLS WAY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9094
Mailing Address - Country:US
Mailing Address - Phone:910-397-2980
Mailing Address - Fax:910-397-2980
Practice Address - Street 1:616 INDIAN WELLS WAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9094
Practice Address - Country:US
Practice Address - Phone:910-397-2980
Practice Address - Fax:910-397-2980
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411536Medicaid