Provider Demographics
NPI:1699505792
Name:KULD, CRYSTAL ELEANOR-BODMER
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELEANOR-BODMER
Last Name:KULD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ELEANOR
Other - Last Name:BODMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:CA
Mailing Address - Zip Code:95971-1222
Mailing Address - Country:US
Mailing Address - Phone:562-896-2574
Mailing Address - Fax:
Practice Address - Street 1:1065 BUCKS LAKE RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:CA
Practice Address - Zip Code:95971-9507
Practice Address - Country:US
Practice Address - Phone:530-283-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist