Provider Demographics
NPI:1194289694
Name:PHAN, CHRYSTAL MARIE
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:MARIE
Last Name:PHAN
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 1:426 BRIGHT CHASE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5196
Mailing Address - Country:US
Mailing Address - Phone:214-405-5694
Mailing Address - Fax:
Practice Address - Street 1:426 BRIGHT CHASE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-5196
Practice Address - Country:US
Practice Address - Phone:214-405-5694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117180235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist