Provider Demographics
NPI:1740915834
Name:LAO, CRYSTAL (LMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:LAO
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 1:7 WHISTLE STOP LN.
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504
Mailing Address - Country:US
Mailing Address - Phone:304-942-7920
Mailing Address - Fax:
Practice Address - Street 1:5841 DAVIS GREEN RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-942-7920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV2002-0887225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist