Provider Demographics
NPI:1881868339
Name:BIRKENSTOCK, CRYSTAL LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:BIRKENSTOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W293N3923 ROUND HILL CIR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3159
Mailing Address - Country:US
Mailing Address - Phone:262-369-1506
Mailing Address - Fax:
Practice Address - Street 1:W293N3923 ROUND HILL CIR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3159
Practice Address - Country:US
Practice Address - Phone:262-369-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1728024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40008900Medicaid