Healthcare Provider Details

I. General information

NPI: 1962817320
Provider Name (Legal Business Name): CRYSTAL DAVISSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 300 N
LOGAN UT
84321-3809
US

IV. Provider business mailing address

1545 TALON DR
LOGAN UT
84321-8268
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-8535
  • Fax: 435-716-8558
Mailing address:
  • Phone: 435-760-7906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number8081794-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: