Provider Demographics
NPI:1477033157
Name:WOOD, CRYSTAL NICOLE (PTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:WOOD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E SONTERRA BLVD APT 5206
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4731
Mailing Address - Country:US
Mailing Address - Phone:214-504-5169
Mailing Address - Fax:
Practice Address - Street 1:8707 LAKESIDE PKWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3245
Practice Address - Country:US
Practice Address - Phone:210-512-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2134818225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant