Provider Demographics
NPI:1336814722
Name:ROSE, CRYSTAL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ROSE
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 1:771 SW GENERAL PATTON TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2657
Mailing Address - Country:US
Mailing Address - Phone:772-607-1282
Mailing Address - Fax:
Practice Address - Street 1:1483 SW BOUGAINVILLEA AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7302
Practice Address - Country:US
Practice Address - Phone:772-337-4208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA20372OtherDEPARTMENT OF HEALTH - LICENSE