Healthcare Provider Details

I. General information

NPI: 1699505792
Provider Name (Legal Business Name): CRYSTAL ELEANOR-BODMER KULD M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL ELEANOR BODMER CCC-SLP

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 WALNUT AVE
VALLEJO CA
94592-1177
US

IV. Provider business mailing address

421 W CARLOS ST
ALTURAS CA
96101-3825
US

V. Phone/Fax

Practice location:
  • Phone: 707-556-8921
  • Fax:
Mailing address:
  • Phone: 562-896-2574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number26963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: