Healthcare Provider Details

I. General information

NPI: 1134459225
Provider Name (Legal Business Name): CRYSTAL JOHANNSSON MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 MAPLE ST
FARMINGTON MO
63640-7641
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DR STE 105
BALLWIN MO
63021-5896
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-9900
  • Fax: 573-756-9988
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2008034892
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: