Provider Demographics
NPI:1063617306
Name:LUXMORE, CRYSTAL MARIE (MA IN PT)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:LUXMORE
Suffix:
Gender:F
Credentials:MA IN PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 TODD ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MN
Mailing Address - Zip Code:55054-5452
Mailing Address - Country:US
Mailing Address - Phone:612-798-8339
Mailing Address - Fax:
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:612-798-8339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7162225100000X, 2251N0400X, 2251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic