Provider Demographics
NPI:1407366073
Name:CRYSTAL, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:CRYSTAL
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 1:201 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5206
Mailing Address - Country:US
Mailing Address - Phone:970-247-5411
Mailing Address - Fax:
Practice Address - Street 1:201 E 12TH ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5206
Practice Address - Country:US
Practice Address - Phone:970-247-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP08343225XP0200X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics