Provider Demographics
NPI:1942404595
Name:JOHNSON, CRYSTAL DALTON (SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DALTON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5347 DAYTONA RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6307
Mailing Address - Country:US
Mailing Address - Phone:540-343-1691
Mailing Address - Fax:
Practice Address - Street 1:1127 PERSINGER RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3829
Practice Address - Country:US
Practice Address - Phone:540-343-1691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist