MEDICARE: CRYSTAL LENIQUE SUMMERHILL RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-24-342440	TX

General Provider Information

NPI Number	:	1598581761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LENIQUE SUMMERHILL RBT

Provider Business Mailing Address
First Line	:	3627 ORCHARD ST
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-7198
Country	:	US
Telephone Number	:	469-343-6390
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 W RUSSELL ST
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5360
Country	:	US
Telephone Number	:	817-694-5073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2024
Last Update Date	:	12/03/2024

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Directions to “ CRYSTAL LENIQUE SUMMERHILL RBT” Practice Location

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