Provider Demographics
NPI:1942719208
Name:LARA, CRYSTAL MIROSALBA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MIROSALBA
Last Name:LARA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 COLMILLO DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-4145
Mailing Address - Country:US
Mailing Address - Phone:915-633-5699
Mailing Address - Fax:
Practice Address - Street 1:1514 N ZARAGOZA RD STE B4
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8041
Practice Address - Country:US
Practice Address - Phone:915-257-5782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112844235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist