Provider Demographics
NPI:1376907832
Name:WARD, CRYSTAL (LMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WARD
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 1:3314 GRANVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-6182
Mailing Address - Country:US
Mailing Address - Phone:931-268-7229
Mailing Address - Fax:
Practice Address - Street 1:3314 GRANVILLE HWY
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-6182
Practice Address - Country:US
Practice Address - Phone:931-268-7229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000008866225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000008866OtherTENNESSEE MASSAGE LICENSURE BOARD