MEDICARE: CRYSTAL MARIE MINNICK LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	TEI002563	PA

General Provider Information

NPI Number	:	1134558711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL MARIE MINNICK LPTA

Provider Business Mailing Address
First Line	:	75 SAND SPRING RD
Second Line	:
City	:	WEATHERLY
State	:	PA
Zip	:	18255-3801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 HAZLE TOWNSHIP BLVD
Second Line	:
City	:	HAZLE TOWNSHIP
State	:	PA
Zip	:	18202-9661
Country	:	US
Telephone Number	:	570-454-8888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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