Healthcare Provider Details

I. General information

NPI: 1891018404
Provider Name (Legal Business Name): MISTY M CRAIG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 NORTHWEST AVE STE 104
TALLMADGE OH
44278-1850
US

IV. Provider business mailing address

PO BOX 6062
AKRON OH
44312-0062
US

V. Phone/Fax

Practice location:
  • Phone: 330-630-1860
  • Fax: 330-630-3198
Mailing address:
  • Phone: 330-630-1860
  • Fax: 330-630-3198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberOH10183
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: