Provider Demographics
NPI:1568411452
Name:MADYDA, CRYSTAL B (PT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:B
Last Name:MADYDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:A
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:90 GROVE ST
Mailing Address - Street 2:SUITE # 106
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-4114
Mailing Address - Country:US
Mailing Address - Phone:203-431-8471
Mailing Address - Fax:203-438-9543
Practice Address - Street 1:90 GROVE ST
Practice Address - Street 2:SUITE # 106
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4114
Practice Address - Country:US
Practice Address - Phone:203-431-8471
Practice Address - Fax:203-438-9543
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080006220OtherANTHEM BC
CT004210150Medicaid
CT004210150Medicaid