Provider Demographics
NPI:1871618231
Name:SMALL, CRYSTAL V (ATC)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:V
Last Name:SMALL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
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Mailing Address - Street 1:111 POND DR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-3202
Mailing Address - Country:US
Mailing Address - Phone:478-987-2754
Mailing Address - Fax:478-987-2749
Practice Address - Street 1:1005 STATE UNIVERSITY DR
Practice Address - Street 2:DEPARTMENT OF ATHLETICS
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-4313
Practice Address - Country:US
Practice Address - Phone:478-825-6195
Practice Address - Fax:478-825-6886
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAAT0013592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2255A2300XOtherATHLETIC TRAINER