Provider Demographics
NPI:1982262499
Name:ADAMAVICH, CRYSTAL (DPT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ADAMAVICH
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:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:970-331-5733
Mailing Address - Fax:
Practice Address - Street 1:201 W LAYTON PKWY FL 3
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-3692
Practice Address - Country:US
Practice Address - Phone:970-331-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11291404-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist