Provider Demographics
NPI:1033482823
Name:FIX, CRYSTAL MONIQUE (ATC/L)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MONIQUE
Last Name:FIX
Suffix:
Gender:F
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 W BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041
Mailing Address - Country:US
Mailing Address - Phone:928-607-4368
Mailing Address - Fax:
Practice Address - Street 1:1492 S MILL AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5652
Practice Address - Country:US
Practice Address - Phone:480-257-2726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-09
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
BOC105800OtherBOARD OF CERTIFICATION
AZ0957OtherARIZONA BOARD OF ATHLETIC TRAINING
1022867OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION