Provider Demographics
NPI:1801467204
Name:STEWART, CRYSTAL (LMT, NMT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1473 N DYSART RD STE 101
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1548
Mailing Address - Country:US
Mailing Address - Phone:623-925-1338
Mailing Address - Fax:
Practice Address - Street 1:1473 N DYSART RD STE 101
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1548
Practice Address - Country:US
Practice Address - Phone:623-925-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-23288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist