Provider Demographics
NPI:1457759292
Name:COLVIN, CRYSTAL LYNN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:COLVIN
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 1:16334 COUNTY ROAD 30
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1207
Mailing Address - Country:US
Mailing Address - Phone:763-416-1799
Mailing Address - Fax:
Practice Address - Street 1:16334 COUNTY ROAD 30
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1207
Practice Address - Country:US
Practice Address - Phone:763-416-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2014-117225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist