Healthcare Provider Details

I. General information

NPI: 1821860933
Provider Name (Legal Business Name): BRITTANY NICOLE CRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 18TH ST
CHARLESTON IL
61920-2382
US

IV. Provider business mailing address

1069 W STATE ST
CHARLESTON IL
61920-1066
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-7054
  • Fax:
Mailing address:
  • Phone: 217-294-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.009958
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: