Provider Demographics
NPI:1255689139
Name:BRYNILDSEN, CRYSTAL MARIE (MS OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:BRYNILDSEN
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:NEALIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4736 ROUTE 467
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:PA
Mailing Address - Zip Code:18837-7969
Mailing Address - Country:US
Mailing Address - Phone:607-222-4074
Mailing Address - Fax:
Practice Address - Street 1:2409 LEVANTE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8020
Practice Address - Country:US
Practice Address - Phone:607-222-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2013-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10264225X00000X
NJ46TR00439600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist