Provider Demographics
NPI:1912310814
Name:DIFFEE, CRYSTAL LOUISE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LOUISE
Last Name:DIFFEE
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 1:5601 HIGHWAY N
Mailing Address - Street 2:
Mailing Address - City:ROBERTSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63072-2662
Mailing Address - Country:US
Mailing Address - Phone:314-609-0912
Mailing Address - Fax:
Practice Address - Street 1:951 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1112
Practice Address - Country:US
Practice Address - Phone:636-462-6098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014029351235Z00000X
MO2013031749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist