Provider Demographics
NPI:1639497498
Name:FRAZEE, CRYSTAL LYNN OGLE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN OGLE
Last Name:FRAZEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:OGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:18000 COVE STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1383
Mailing Address - Country:US
Mailing Address - Phone:616-847-1280
Mailing Address - Fax:616-847-1290
Practice Address - Street 1:18000 COVE STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1383
Practice Address - Country:US
Practice Address - Phone:616-847-1280
Practice Address - Fax:616-847-1290
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP147600011Medicare PIN