Provider Demographics
NPI:1619185048
Name:KOPPAL, CRYSTAL MOORE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MOORE
Last Name:KOPPAL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2565
Mailing Address - Country:US
Mailing Address - Phone:352-371-1865
Mailing Address - Fax:352-332-9941
Practice Address - Street 1:1034 NW 57TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-6452
Practice Address - Country:US
Practice Address - Phone:352-332-9015
Practice Address - Fax:352-332-9941
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist