=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033502422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL HENLEY OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2015
-----------------------------------------------------
Last Update Date | 03/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 S PETERS RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-5204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-221-1280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 394 SCANDLYN HOLLOW RD
-----------------------------------------------------
City | OLIVER SPRINGS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37840-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-221-1280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 3282
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------