Provider Demographics
NPI:1205068681
Name:O'MALLEY, CRYSTAL LEE KIECKHOEFER (MSE, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LEE KIECKHOEFER
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:MSE, CCC-SLP
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:LEE
Other - Last Name:KIECKHOEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSE, CCC-SLP
Mailing Address - Street 1:1891 STATION PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4259
Mailing Address - Country:US
Mailing Address - Phone:763-755-4275
Mailing Address - Fax:
Practice Address - Street 1:1891 STATION PKWY NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4259
Practice Address - Country:US
Practice Address - Phone:763-755-4275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8889235Z00000X
WI3282-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist