Provider Demographics
NPI:1689247405
Name:HEARN, CRYSTAL A
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:HEARN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 KIRKWOOD HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-4939
Mailing Address - Country:US
Mailing Address - Phone:302-777-0778
Mailing Address - Fax:
Practice Address - Street 1:1702 KIRKWOOD HWY STE 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4939
Practice Address - Country:US
Practice Address - Phone:302-777-0778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0015110225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty