Provider Demographics
NPI:1356747885
Name:STEPHENS, CRYSTAL (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:MICHELL
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31044-3723
Mailing Address - Country:US
Mailing Address - Phone:478-945-0183
Mailing Address - Fax:
Practice Address - Street 1:61 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:31044-3723
Practice Address - Country:US
Practice Address - Phone:478-945-0183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001068224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant