Provider Demographics
NPI:1780978486
Name:THEIS, CRYSTAL (DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:THEIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 NW 45TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-4613
Mailing Address - Country:US
Mailing Address - Phone:816-451-1633
Mailing Address - Fax:816-451-1635
Practice Address - Street 1:851 NW 45TH ST STE 209
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4613
Practice Address - Country:US
Practice Address - Phone:816-451-1633
Practice Address - Fax:816-451-1635
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011020077OtherPT LICENSE #