Provider Demographics
NPI:1861664377
Name:THOMAS, CRYSTAL RENE (PT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:RENE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:RENE
Other - Last Name:KIEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:144 W LOS ANGELES AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1898
Mailing Address - Country:US
Mailing Address - Phone:805-552-1915
Mailing Address - Fax:805-552-1991
Practice Address - Street 1:144 W LOS ANGELES AVE
Practice Address - Street 2:STE 110
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1898
Practice Address - Country:US
Practice Address - Phone:805-552-1915
Practice Address - Fax:805-552-1991
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT327072251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT32707OtherPT LICENSE