Healthcare Provider Details

I. General information

NPI: 1245488295
Provider Name (Legal Business Name): CRYSTAL LEITZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

12115 PANAMA CITY BEACH PKWY
PANAMA CITY FL
32407-2609
US

IV. Provider business mailing address

921 PELICAN PL
PANAMA CITY FL
32407-2602
US

V. Phone/Fax

Practice location:
  • Phone: 850-236-5664
  • Fax:
Mailing address:
  • Phone: 850-814-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA25863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: