Provider Demographics
NPI:1255167672
Name:SPENCE, CRYSTAL DAWN (LMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:SPENCE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 THORNTON AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-8849
Mailing Address - Country:US
Mailing Address - Phone:540-599-1607
Mailing Address - Fax:
Practice Address - Street 1:615 ROGERS ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3649
Practice Address - Country:US
Practice Address - Phone:540-599-1607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2024-4114225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist