Provider Demographics
NPI:1417002064
Name:DAVIS, CRYSTAL L (LMP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:HOTTELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:224 PAINE RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-8708
Mailing Address - Country:US
Mailing Address - Phone:360-274-2353
Mailing Address - Fax:360-274-2354
Practice Address - Street 1:139 1ST AVE. SW
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-274-2353
Practice Address - Fax:360-274-2354
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019024225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1055113OtherAMERICAN SPECIALTY HEALTH
WA3804HOOtherREGENCE BLUE SHIELD