Basic Information
| Provider Information | |||||||||
| NPI: | 1649411828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAGNO | ||||||||
| FirstName: | CRISELIZ | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10450 NORTHERN DANCER DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462349850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176956126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 N. WABASH AVE. SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656513229 | ||||||||
| FaxNumber: | 7656513227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009299A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.