Provider Demographics
NPI:1477919017
Name:BOLANOS-MALDONADO, CRYSTAL S (MS PT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:S
Last Name:BOLANOS-MALDONADO
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:S
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PT
Mailing Address - Street 1:3910 GOFORTH DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-8529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3910 GOFORTH DR
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-8529
Practice Address - Country:US
Practice Address - Phone:336-324-8741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP13978OtherNC PT LICENSE NUMBER