Provider Demographics
NPI:1497413488
Name:UNDERWOOD, CRYSTAL (PTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:UNDERWOOD
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 1:619 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-3418
Mailing Address - Country:US
Mailing Address - Phone:479-474-0041
Mailing Address - Fax:479-474-0099
Practice Address - Street 1:619 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3418
Practice Address - Country:US
Practice Address - Phone:479-474-0041
Practice Address - Fax:479-474-0099
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4713225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty