MEDICARE: CRYSTAL LEITZ

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	225700000X	Massage Therapist	MA25863	FL

General Provider Information

NPI Number	:	1245488295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LEITZ

Provider Business Mailing Address
First Line	:	921 PELICAN PL
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32407-2602
Country	:	US
Telephone Number	:	850-814-9778
Fax Number	:

Provider Business Practice Location Address
First Line	:	12115 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32407-2609
Country	:	US
Telephone Number	:	850-236-5664
Fax Number	:

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

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	09/03/2008

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Directions to “ CRYSTAL LEITZ ” Practice Location

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