Provider Demographics
NPI:1962539858
Name:CRISSMAN, MAVILYN (PT)
Entity type:Individual
Prefix:
First Name:MAVILYN
Middle Name:
Last Name:CRISSMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MAVILYN
Other - Middle Name:
Other - Last Name:GENCIANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 N CRESTHAVEN AVE
Mailing Address - Street 2:APT C101
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-7826
Mailing Address - Country:US
Mailing Address - Phone:870-416-6834
Mailing Address - Fax:610-347-4147
Practice Address - Street 1:501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3535
Practice Address - Country:US
Practice Address - Phone:870-743-5573
Practice Address - Fax:870-743-5974
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist