Provider Demographics
NPI:1700215662
Name:HENRY, CRYSTAL D (OTR/L,CHT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:HENRY
Suffix:
Gender:F
Credentials:OTR/L,CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:686 COUNTY ROAD 123
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72661-9183
Mailing Address - Country:US
Mailing Address - Phone:870-424-2224
Mailing Address - Fax:870-424-0493
Practice Address - Street 1:715 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3421
Practice Address - Country:US
Practice Address - Phone:870-424-2224
Practice Address - Fax:870-424-0493
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1340225X00000X, 225XE0001X, 225XH1200X, 225XN1300X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR345896ZGR9Medicare PIN