Provider Demographics
NPI:1992283634
Name:GREEN, KRYSTAL NICOLE (SLPA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 SW LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2079
Mailing Address - Country:US
Mailing Address - Phone:772-971-1439
Mailing Address - Fax:
Practice Address - Street 1:549 NW LAKE WHITNEY PL STE 104
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1606
Practice Address - Country:US
Practice Address - Phone:772-301-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11217235Z00000X
FL33942355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty