Healthcare Provider Details

I. General information

NPI: 1710687009
Provider Name (Legal Business Name): CRYSTAL RENEE MEADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 E ELM ST
NASHVILLE IL
62263-1768
US

IV. Provider business mailing address

541 E ELM ST
NASHVILLE IL
62263-1768
US

V. Phone/Fax

Practice location:
  • Phone: 618-409-1155
  • Fax:
Mailing address:
  • Phone: 618-409-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: