Provider Demographics
NPI:1588384481
Name:CRIST, EMMA C (LAT, ATC)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:C
Last Name:CRIST
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14360 COUNTY SHOP RD
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53530-9249
Mailing Address - Country:US
Mailing Address - Phone:608-482-4323
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-890-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0041992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer