Provider Demographics
NPI:1558979807
Name:HIBBERT, CRYSTAL (COTA/L)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:HIBBERT
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-1834
Mailing Address - Country:US
Mailing Address - Phone:484-725-4774
Mailing Address - Fax:
Practice Address - Street 1:13385 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2631
Practice Address - Country:US
Practice Address - Phone:623-986-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-046826224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant