Healthcare Provider Details

I. General information

NPI: 1508929704
Provider Name (Legal Business Name): DENISE E CRISWELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N LIMESTONE ST
SPRINGFIELD OH
45503-1114
US

IV. Provider business mailing address

2829 WALNUT GROVE LN
SPRINGFIELD OH
45504-4355
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-5600
  • Fax:
Mailing address:
  • Phone: 937-390-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 002663
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: