Basic Information
| Provider Information | |||||||||
| NPI: | 1053871095 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KRYSTAL TEMPLES GAITHER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 736 HIGHLAND CIR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316395807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2296860771 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 736 HIGHLAND CIR | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316395807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2296860771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2019 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAITHER | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/SLP | ||||||||
| AuthorizedOfficialTelephone: | 2296860771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MED CCC-SLP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 577891570 | 05 | GA | MEDICAID |