MEDICARE: CRYSTAL BEARD-ODOM LMT

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	MT.0022637	CO

General Provider Information

NPI Number	:	1942928684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL BEARD-ODOM LMT

Provider Business Mailing Address
First Line	:	2214 GREENWICH CIR W
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-1622
Country	:	US
Telephone Number	:	719-310-1501
Fax Number	:

Provider Business Practice Location Address
First Line	:	2924 BEACON ST STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6195
Country	:	US
Telephone Number	:	719-301-9802
Fax Number	:

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

Provider Enumeration Date	:	08/18/2022
Last Update Date	:	03/22/2023

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