Provider Demographics
NPI:1962730234
Name:MCCLENAHAN, KRYSTAL MARIE (MPT)
Entity type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:MARIE
Last Name:MCCLENAHAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11803 FRUIT RD
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:IL
Mailing Address - Zip Code:62001-2909
Mailing Address - Country:US
Mailing Address - Phone:618-977-0336
Mailing Address - Fax:
Practice Address - Street 1:200 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist