Provider Demographics
NPI:1275182057
Name:LUSK, CRYSTAL DAWN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:LUSK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:JEFFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 MACCORKLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2326
Mailing Address - Country:US
Mailing Address - Phone:304-768-0002
Mailing Address - Fax:
Practice Address - Street 1:6500 MACCORKLE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2326
Practice Address - Country:US
Practice Address - Phone:304-768-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV003371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist