Healthcare Provider Details

I. General information

NPI: 1063617306
Provider Name (Legal Business Name): CRYSTAL MARIE LUXMORE M.A. IN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W 64TH ST
MINNEAPOLIS MN
55423-1001
US

IV. Provider business mailing address

70 TODD ST
NEW MARKET MN
55054-5452
US

V. Phone/Fax

Practice location:
  • Phone: 612-798-8339
  • Fax:
Mailing address:
  • Phone: 612-798-8339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7162
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number7162
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number7162
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number7162
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: