Provider Demographics
NPI:1730364753
Name:LANE, CRYSTAL BETH (PT, DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:BETH
Last Name:LANE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 TERAVISTA PKWY APT 821
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1296
Mailing Address - Country:US
Mailing Address - Phone:325-864-3633
Mailing Address - Fax:
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6249
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-519-3477
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11800062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics