Provider Demographics
NPI:1073092847
Name:TAYLOR, CRYSTAL RENEE (CTRS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 LEGACY BLVD APT 727
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-2609
Mailing Address - Country:US
Mailing Address - Phone:252-315-9890
Mailing Address - Fax:
Practice Address - Street 1:45629 MANDALAY CIR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48315-6843
Practice Address - Country:US
Practice Address - Phone:252-315-9890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-12
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC67206225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist