Provider Demographics
NPI:1700168689
Name:BARTUCCI, CRYSTAL (PTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BARTUCCI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14550 AVERS AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2812
Mailing Address - Country:US
Mailing Address - Phone:708-768-7165
Mailing Address - Fax:
Practice Address - Street 1:11531 SWINFORD LN
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9274
Practice Address - Country:US
Practice Address - Phone:219-229-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005775225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant