Basic Information
| Provider Information | |||||||||
| NPI: | 1205998630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEVENS | ||||||||
| OtherFirstName: | CRYSTAL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | LPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9300 STONESTREET RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402722876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029359776 | ||||||||
| FaxNumber: | 5029359813 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 STONESTREET RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402722876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029359776 | ||||||||
| FaxNumber: | 5029359813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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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 | 2251X0800X | 004317 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 000000346353 | 01 | KY | ANTHEM BLUE SHIELD | OTHER | P00417175 | 01 | KY | RAILROAD MEDICARE | OTHER |