Provider Demographics
NPI:1740009547
Name:COOPER, CRYSTAL JOE (LMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JOE
Last Name:COOPER
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 1:5645 LORD ST
Mailing Address - Street 2:
Mailing Address - City:MIMS
Mailing Address - State:FL
Mailing Address - Zip Code:32754-6908
Mailing Address - Country:US
Mailing Address - Phone:240-320-4268
Mailing Address - Fax:
Practice Address - Street 1:1750 RINEHART RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6590
Practice Address - Country:US
Practice Address - Phone:321-578-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA99772225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist