Provider Demographics
NPI:1366601817
Name:CRAWFORD, MYRA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:MARIE
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5509 N PENNSYLVANIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3023
Mailing Address - Country:US
Mailing Address - Phone:317-726-0277
Mailing Address - Fax:317-872-3234
Practice Address - Street 1:5509 N PENNSYLVANIA ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3023
Practice Address - Country:US
Practice Address - Phone:317-726-0277
Practice Address - Fax:317-872-3234
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003383A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant