Healthcare Provider Details

I. General information

NPI: 1962539858
Provider Name (Legal Business Name): MAVILYN CRISSMAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAVILYN GENCIANA

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N MAIN ST
HARRISON AR
72601-3535
US

IV. Provider business mailing address

2601 N CRESTHAVEN AVE APT C101
SPRINGFIELD MO
65803-7826
US

V. Phone/Fax

Practice location:
  • Phone: 870-743-5573
  • Fax: 870-743-5974
Mailing address:
  • Phone: 870-416-6834
  • Fax: 610-347-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2971
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: