Provider Demographics
NPI:1851697239
Name:CONSALVO, CRYSTAL ANN (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:ANN
Last Name:CONSALVO
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BRASSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-3411
Mailing Address - Country:US
Mailing Address - Phone:631-786-8185
Mailing Address - Fax:
Practice Address - Street 1:710 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1226
Practice Address - Country:US
Practice Address - Phone:203-329-4026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63015038225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY63015038OtherOCCUPATIONAL THERAPIST NY LICENSE NUMBER