MEDICARE: CRYSTAL LYNN SPEIRS PTA

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	PTA9691	AZ

General Provider Information

NPI Number	:	1245590975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LYNN SPEIRS PTA

Provider Business Mailing Address
First Line	:	375 E VIRGINIA AVE
Second Line	:	SUITE B
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1220
Country	:	US
Telephone Number	:	602-264-5323
Fax Number	:	602-264-5302

Provider Business Practice Location Address
First Line	:	375 E VIRGINIA AVE
Second Line	:	SUITE B
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1220
Country	:	US
Telephone Number	:	602-264-5323
Fax Number	:	602-264-5302

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

Provider Enumeration Date	:	05/29/2012
Last Update Date	:	05/29/2012

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