MEDICARE: CRYSTAL PAVIS LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1568240406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL PAVIS LMT

Provider Business Mailing Address
First Line	:	32 CORTLAND ST
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1406
Country	:	US
Telephone Number	:	203-903-4566
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 FISHER DR
Second Line	:
City	:	AVON
State	:	CT
Zip	:	06001-3798
Country	:	US
Telephone Number	:	860-674-0088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2023
Last Update Date	:	09/21/2023

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