Healthcare Provider Details

I. General information

NPI: 1366483018
Provider Name (Legal Business Name): CRYSTAL LYNN HOLLINGSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 8TH AVE NW
FARIBAULT MN
55021-5068
US

IV. Provider business mailing address

200 8TH AVE NW
FARIBAULT MN
55021-5068
US

V. Phone/Fax

Practice location:
  • Phone: 507-334-5627
  • Fax: 507-334-1824
Mailing address:
  • Phone: 507-334-5627
  • Fax: 507-334-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2562
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: