Provider Demographics
NPI:1700932712
Name:COUILLARD, CRYSTEL L (LMP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTEL
Middle Name:L
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 MULLEN RD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4577
Mailing Address - Country:US
Mailing Address - Phone:360-786-6322
Mailing Address - Fax:360-786-5677
Practice Address - Street 1:2627 CAPITOL MALL DR SW
Practice Address - Street 2:STEB3A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8696
Practice Address - Country:US
Practice Address - Phone:360-786-6322
Practice Address - Fax:360-284-9801
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist