Provider Demographics
NPI:1104248616
Name:CHRISTAL, AUDRA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:CHRISTAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 126TH ST W
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:IL
Mailing Address - Zip Code:61232-9235
Mailing Address - Country:US
Mailing Address - Phone:702-682-8372
Mailing Address - Fax:
Practice Address - Street 1:8020 126TH ST W
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:IL
Practice Address - Zip Code:61232-9235
Practice Address - Country:US
Practice Address - Phone:702-682-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12312015225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL123112015OtherLISENCE NUMBER OT