Healthcare Provider Details

I. General information

NPI: 1093528424
Provider Name (Legal Business Name): KRYSTAL MARIE CAPIZZO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23200 GREATER MACK AVE STE 9
SAINT CLAIR SHORES MI
48080-3422
US

IV. Provider business mailing address

23200 GREATER MACK AVE STE 9
SAINT CLAIR SHORES MI
48080-3422
US

V. Phone/Fax

Practice location:
  • Phone: 313-744-3720
  • Fax:
Mailing address:
  • Phone: 313-744-3720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501002652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: