Provider Demographics
NPI:1457517112
Name:CROSSLEY, CHAD LUCKETT (PT, DPT, MS, OCS, AT)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:LUCKETT
Last Name:CROSSLEY
Suffix:
Gender:M
Credentials:PT, DPT, MS, OCS, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 NE TANAGER ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-4801
Mailing Address - Country:US
Mailing Address - Phone:412-478-2212
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME AFB
Practice Address - State:ID
Practice Address - Zip Code:83648
Practice Address - Country:US
Practice Address - Phone:412-432-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019425225100000X
AZ9743PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist