Provider Demographics
NPI:1477038636
Name:BROWN, CRYSTAL (PT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:FRAKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:15 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FRUITPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49415-9631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2331 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1954
Practice Address - Country:US
Practice Address - Phone:616-785-2619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist