Provider Demographics
NPI:1588969802
Name:BALTHAZOR, CRYSTAL ANN (COTA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-3904
Mailing Address - Country:US
Mailing Address - Phone:316-283-6600
Mailing Address - Fax:316-283-6375
Practice Address - Street 1:1035 SE 3RD ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-3904
Practice Address - Country:US
Practice Address - Phone:316-283-6600
Practice Address - Fax:316-283-6375
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00729224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant