=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003002247
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL TEMPLES GAITHER MED. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2007
-----------------------------------------------------
Last Update Date | 03/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 736 HIGHLAND CIR
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31639-5807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-686-0771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 736 HIGHLAND CIR
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31639-5807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-686-0771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP005735
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------