Provider Demographics
NPI:1285104307
Name:RAE, CRYSTAL (PTA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:RAE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 FRENCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:ME
Mailing Address - Zip Code:04979-3114
Mailing Address - Country:US
Mailing Address - Phone:207-399-8488
Mailing Address - Fax:
Practice Address - Street 1:7 HIGHWOOD ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5739
Practice Address - Country:US
Practice Address - Phone:207-873-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA5213225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant