Provider Demographics
NPI:1407327729
Name:LARIOS, CRYSTAL MICHELLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:LARIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 BRADEN CRES
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2108
Mailing Address - Country:US
Mailing Address - Phone:757-724-1407
Mailing Address - Fax:
Practice Address - Street 1:WESTMINSTER CANTERBURY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451
Practice Address - Country:US
Practice Address - Phone:757-496-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-14
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602413225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1796563OtherOPTIMA HEALTH