Provider Demographics
NPI:1730355264
Name:COTHERN, CRYSTAL (LMT)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:COTHERN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5111
Mailing Address - Country:US
Mailing Address - Phone:813-685-4222
Mailing Address - Fax:813-689-3832
Practice Address - Street 1:113 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5111
Practice Address - Country:US
Practice Address - Phone:813-685-4222
Practice Address - Fax:813-689-3832
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA46309225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist