Provider Demographics
NPI:1417521584
Name:SMITH, CRYSTAL DAWN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:DAWN
Other - Last Name:RANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1934 S GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2305
Mailing Address - Country:US
Mailing Address - Phone:417-887-0340
Mailing Address - Fax:417-887-0445
Practice Address - Street 1:1934 S GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2305
Practice Address - Country:US
Practice Address - Phone:417-887-0340
Practice Address - Fax:417-887-0445
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011022469225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty