Healthcare Provider Details

I. General information

NPI: 1043175151
Provider Name (Legal Business Name): CRYSTAL KEAGLE MOT, OTR/L, CSOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9855 OAK COLONY DR
BATON ROUGE LA
70817-5550
US

IV. Provider business mailing address

9855 OAK COLONY DR
BATON ROUGE LA
70817-5550
US

V. Phone/Fax

Practice location:
  • Phone: 318-243-5004
  • Fax:
Mailing address:
  • Phone: 318-243-5004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number334894
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: