Provider Demographics
NPI:1205335767
Name:KINDER, CRYSTAL LEIGH
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEIGH
Last Name:KINDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 SIX FARM RD
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-9172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 BAGLEY CIR STE 300
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-3140
Practice Address - Country:US
Practice Address - Phone:276-783-3751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
VA2202006712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202006712Medicaid