Provider Demographics
NPI:1134455538
Name:GENTRY, CRYSTAL (SLP/MS-CCC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:SLP/MS-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572070
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-2070
Mailing Address - Country:US
Mailing Address - Phone:801-263-7138
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3562
Practice Address - Country:US
Practice Address - Phone:888-949-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10552937-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist