Provider Demographics
NPI:1073702593
Name:COOK, CRYSTAL J (LPTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:COOK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:
Practice Address - Street 1:711 AVIGNON DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5120
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-21
Last Update Date:2007-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA3389225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant