Basic Information
| Provider Information | |||||||||
| NPI: | 1053494534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 MAPLE STREET | ||||||||
| Address2: | PO BOX 240 | ||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 240 MAPLE STREET | ||||||||
| Address2: | |||||||||
| City: | WOODRUFF | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545680470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153568000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4166-026 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40872000 | 05 | WI | MEDICAID |