Provider Demographics
NPI:1760105787
Name:MAIDEN, KRYSTAL (LCMT, LE)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:MAIDEN
Suffix:
Gender:F
Credentials:LCMT, LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 140TH PL
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-3352
Mailing Address - Country:US
Mailing Address - Phone:773-879-5640
Mailing Address - Fax:
Practice Address - Street 1:17222 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3368
Practice Address - Country:US
Practice Address - Phone:708-468-8957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227014737225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist