Provider Demographics
NPI:1457581613
Name:CRYSTAL CLEAR SPEECH AND LANGUAGE SERVICES
Entity type:Organization
Organization Name:CRYSTAL CLEAR SPEECH AND LANGUAGE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:LACY
Authorized Official - Last Name:MCQUITTY
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:336-638-4637
Mailing Address - Street 1:1901 DEIDRE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8697
Mailing Address - Country:US
Mailing Address - Phone:336-638-4637
Mailing Address - Fax:336-638-4637
Practice Address - Street 1:1901 DEIDRE CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8697
Practice Address - Country:US
Practice Address - Phone:336-638-4637
Practice Address - Fax:336-638-4637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411784Medicaid