Krystal Maiden, LCMT, LE – Massage Therapist

Key facts

NPI: 1760105787
Entity type: Individual (NPI type 1)
Primary specialty: Massage Therapist 225700000X
License: 227014737 (IL)
Practice address: 17222 Harlem Ave
Tinley Park, IL 60477-3368
Phone: (708) 468-8957
NPI assigned: Sep 23, 2022
Sex: Female
Sole proprietor: No

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No

State licenses

License	State	Type	Specialty
227014737	IL	MD	Massage Therapist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Massage Therapist	225700000X	227014737	IL	Yes

Addresses

Primary practice location

17222 Harlem Ave
Tinley Park, IL 60477-3368

Mailing address

2805 140TH PL
Blue Island, IL 60406-3352
Phone (773) 879-5640

Electronic endpoints

Type	Endpoint	Use	Affiliation
Direct Messaging Address	contact@ndulj.net	Direct

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Sep 23, 2022.

{
    "created_epoch": "1663891200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663891200000",
    "number": "1760105787",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2805 140TH PL",
            "city": "BLUE ISLAND",
            "state": "IL",
            "postal_code": "604063352",
            "telephone_number": "773-879-5640"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17222 HARLEM AVE",
            "city": "TINLEY PARK",
            "state": "IL",
            "postal_code": "604773368",
            "telephone_number": "708-468-8957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MAIDEN",
        "first_name": "KRYSTAL",
        "credential": "LCMT, LE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-09-23",
        "last_updated": "2022-09-23",
        "certification_date": "2022-09-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225700000X",
            "taxonomy_group": "",
            "desc": "Massage Therapist",
            "state": "IL",
            "license": "227014737",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "contact@ndulj.net",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "17222 Harlem Ave",
            "city": "Tinley Park",
            "state": "IL",
            "country_code": "US",
            "postal_code": "604773368",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Tinley Park, IL

All providers in Tinley Park, IL · Massage Therapist in Illinois

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 23, 2022. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.