Healthcare Provider Details

I. General information

NPI: 1205407533
Provider Name (Legal Business Name): KRYSTAL WALLS MSOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5865 SUGAR LN
PLAINFIELD IN
46168-8328
US

IV. Provider business mailing address

324 N COUNTY ROAD 325 W
DANVILLE IN
46122-8854
US

V. Phone/Fax

Practice location:
  • Phone: 317-839-7900
  • Fax:
Mailing address:
  • Phone: 317-446-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number31004676A
License Number StateIN

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: