MEDICARE: CRYSTAL MARTIN

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1811408776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL MARTIN

Provider Business Mailing Address
First Line	:	170 S GREEN VALLEY PKWY
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89012-3132
Country	:	US
Telephone Number	:	800-615-2361
Fax Number	:

Provider Business Practice Location Address
First Line	:	170 S GREEN VALLEY PKWY
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89012-3132
Country	:	US
Telephone Number	:	800-615-2361
Fax Number	:	866-948-8607

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

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	10/18/2017

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Directions to “ CRYSTAL MARTIN ” Practice Location

Language	Start Address	Practice Location

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