Provider Demographics
NPI:1710441837
Name:HEWITT, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:HEWITT
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 1:14400 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44618-9752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 WABASH AVE N
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:OH
Practice Address - Zip Code:44613-1042
Practice Address - Country:US
Practice Address - Phone:330-767-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.005963224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant