Provider Demographics
NPI:1073372835
Name:CAMPUS, CRYSTAL MARIE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:CAMPUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 N CRYSTAL LAKE DR APT 72
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6587
Mailing Address - Country:US
Mailing Address - Phone:708-205-8186
Mailing Address - Fax:
Practice Address - Street 1:1836 N CRYSTAL LAKE DR APT 72
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6587
Practice Address - Country:US
Practice Address - Phone:708-205-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist