Healthcare Provider Details

I. General information

NPI: 1679462774
Provider Name (Legal Business Name): CRYSTAL BURT RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 REX LAKE RD, LEEDS, AL 35094 101
LEEDS AL
35094
US

IV. Provider business mailing address

350 REX LAKE RD, LEEDS, AL 35094 101
LEEDS AL
35094
US

V. Phone/Fax

Practice location:
  • Phone: 312-965-2997
  • Fax:
Mailing address:
  • Phone: 312-965-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1305905
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: