Basic Information
Provider Information | |||||||||
NPI: | 1306149182 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIMS | ||||||||
FirstName: | CRYSTAL | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT, OCS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIESEL | ||||||||
OtherFirstName: | CRYSTAL | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5005 N PIEDRAS ST | ||||||||
Address2: | ATTN: CREDENTIALS | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799205001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9155694432 | ||||||||
FaxNumber: | 9155694890 | ||||||||
Practice Location | |||||||||
Address1: | 401 CARPENTER RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | FORT MYER | ||||||||
State: | VA | ||||||||
PostalCode: | 222111009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7036963442 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2010 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1189678 | TX | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2251X0800X | 10019349 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
ID | Type | State | Issuer | Description | 1292876510 | 05 | TX |   | MEDICAID |