Provider Demographics
NPI:1124281142
Name:UDEHN, CRYSTAL ROWAN-CLAIRE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROWAN-CLAIRE
Last Name:UDEHN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:M
Other - Last Name:UDEHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:28780 SINGLE OAK DR
Practice Address - Street 2:STE. 290
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-3625
Practice Address - Country:US
Practice Address - Phone:951-693-5871
Practice Address - Fax:951-693-5872
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0237659OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES
CASP0134780OtherBLUE SHIELD
CABX053YMedicare PIN
WA0237659OtherSTATE OF WASHINGTON DEPT. OF LABOR AND INDUSTRIES