Provider Demographics
NPI:1366527921
Name:ROSS, CRYSTAL (ST)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 HORNED OWL DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1928
Mailing Address - Country:US
Mailing Address - Phone:832-293-0660
Mailing Address - Fax:
Practice Address - Street 1:21304 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:832-293-0660
Practice Address - Fax:800-803-7888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354252401Medicaid