Provider Demographics
NPI:1164067609
Name:SPENCER, CRYSTAL LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:SPENCER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9407 N. GOVERNMENT WAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7414
Mailing Address - Country:US
Mailing Address - Phone:208-659-2296
Mailing Address - Fax:208-659-2296
Practice Address - Street 1:9407 N GOVERNMENT WAY
Practice Address - Street 2:SUITE 3
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-7414
Practice Address - Country:US
Practice Address - Phone:208-659-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID455329257OtherMASSAGE THERAPY