Provider Demographics
NPI:1194074740
Name:ACKERMANN, KRYSTAL LYNNE (PT)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNNE
Last Name:ACKERMANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LYNNE
Other - Last Name:CSUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2535 IRA E WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3930
Mailing Address - Country:US
Mailing Address - Phone:817-481-2121
Mailing Address - Fax:817-488-4493
Practice Address - Street 1:2535 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3930
Practice Address - Country:US
Practice Address - Phone:817-481-2121
Practice Address - Fax:817-488-4493
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1217600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1217600OtherSTATE LICENSE