Provider Demographics
NPI:1942463559
Name:STEVENSON, CRYSTAL DAKOTA (LMT, NCTMB, CIMI)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAKOTA
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:LMT, NCTMB, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7722 S SANGAMON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-2810
Mailing Address - Country:US
Mailing Address - Phone:773-793-0676
Mailing Address - Fax:
Practice Address - Street 1:7722 S SANGAMON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-2810
Practice Address - Country:US
Practice Address - Phone:773-793-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.008055225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist