Provider Demographics
NPI:1487124764
Name:MATIAS, CRYSTAL (SPEECH LANGUAGE PATH)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MATIAS
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 SEAMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2632
Mailing Address - Country:US
Mailing Address - Phone:323-806-4607
Mailing Address - Fax:
Practice Address - Street 1:620 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1220
Practice Address - Country:US
Practice Address - Phone:626-793-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist