Provider Demographics
NPI:1316993942
Name:ANTHONY, CRYSTAL CORRINE (DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CORRINE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:CORRINE
Other - Last Name:NYBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:25150 HANCOCK AVE STE 100
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5988
Practice Address - Country:US
Practice Address - Phone:951-698-7720
Practice Address - Fax:951-698-7451
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT268400OtherBLUE SHIELD
CABJ829XMedicare PIN
CABJ829YMedicare PIN
CA0PT268400OtherBLUE SHIELD