Provider Demographics
NPI:1629515903
Name:WEIR, CRYSTAL (LMBT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WEIR
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7016 VOIGHT RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1520
Mailing Address - Country:US
Mailing Address - Phone:704-996-6258
Mailing Address - Fax:
Practice Address - Street 1:4023 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1544
Practice Address - Country:US
Practice Address - Phone:704-996-6258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG007318173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist