Provider Demographics
NPI:1396080545
Name:STEPHEN, CRYSTAL LYNN (MOT, OTR)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:STEPHEN
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12803 LENOVER ST
Mailing Address - Street 2:
Mailing Address - City:DILLSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:47018-9418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12803 LENOVER ST
Practice Address - Street 2:
Practice Address - City:DILLSBORO
Practice Address - State:IN
Practice Address - Zip Code:47018-9418
Practice Address - Country:US
Practice Address - Phone:812-432-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005266A225X00000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100273840Medicaid