Provider Demographics
NPI:1578294054
Name:VEGA, CRYSTAL ELISABETH (OTR)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELISABETH
Last Name:VEGA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7105 VILLA PANCHO DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-6229
Mailing Address - Country:US
Mailing Address - Phone:956-293-0879
Mailing Address - Fax:
Practice Address - Street 1:2200 BOCA CHICA BLVD STE 120
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2217
Practice Address - Country:US
Practice Address - Phone:956-621-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122805225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist