Provider Demographics
NPI:1265902357
Name:LANE, CRYSTAL V (OTR/L)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:V
Last Name:LANE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14715 BRISTOW RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20112-3945
Mailing Address - Country:US
Mailing Address - Phone:703-791-7200
Mailing Address - Fax:
Practice Address - Street 1:14715 BRISTOW RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3945
Practice Address - Country:US
Practice Address - Phone:703-791-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119007343225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist