Provider Demographics
NPI:1669607420
Name:FORREST, CRYSTAL MARIE (LMBT)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:FORREST
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46527 RANDALLS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28128
Mailing Address - Country:US
Mailing Address - Phone:704-984-2553
Mailing Address - Fax:704-474-3568
Practice Address - Street 1:46527 RANDALLS CHURCH RD
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:NC
Practice Address - Zip Code:28128
Practice Address - Country:US
Practice Address - Phone:704-984-2553
Practice Address - Fax:704-474-3568
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC#1634225700000X
#286332-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist