Healthcare Provider Details

I. General information

NPI: 1508018045
Provider Name (Legal Business Name): CRYSTAL CONYERS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11153 E SONRISA AVE
MESA AZ
85212-5149
US

IV. Provider business mailing address

453 W NOPAL AVE
MESA AZ
85210-7414
US

V. Phone/Fax

Practice location:
  • Phone: 307-399-9765
  • Fax:
Mailing address:
  • Phone: 307-399-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8235
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: