Healthcare Provider Details

I. General information

NPI: 1699601898
Provider Name (Legal Business Name): CRYSTAL LYNNE GOERTZEN OTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16767 BLANTON VIEW AVE
WAYNE OK
73095-3149
US

IV. Provider business mailing address

16767 BLANTON VIEW AVE
WAYNE OK
73095-3149
US

V. Phone/Fax

Practice location:
  • Phone: 405-630-9238
  • Fax:
Mailing address:
  • Phone: 405-630-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1399
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: