Provider Demographics
NPI:1124167739
Name:CHAMPION, CRYSTAL A (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3742 GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6334
Mailing Address - Country:US
Mailing Address - Phone:706-631-1030
Mailing Address - Fax:
Practice Address - Street 1:3742 GREENWICH AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6334
Practice Address - Country:US
Practice Address - Phone:706-631-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist