Healthcare Provider Details

I. General information

NPI: 1730660838
Provider Name (Legal Business Name): DEJA CRYSTAL NETZ DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5067
US

IV. Provider business mailing address

1334 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5067
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-3317
  • Fax: 505-292-3402
Mailing address:
  • Phone: 505-292-3317
  • Fax: 505-292-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5319
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: