Basic Information
| Provider Information | |||||||||
| NPI: | 1871618231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 POND DR | ||||||||
| Address2: | |||||||||
| City: | KATHLEEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310473202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789872754 | ||||||||
| FaxNumber: | 4789872749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 STATE UNIVERSITY DR | ||||||||
| Address2: | DEPARTMENT OF ATHLETICS | ||||||||
| City: | FORT VALLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310304313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788256195 | ||||||||
| FaxNumber: | 4788256886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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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 | 2255A2300X | AT001359 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2255A2300X | 01 | GA | ATHLETIC TRAINER | OTHER |