Healthcare Provider Details

I. General information

NPI: 1699801803
Provider Name (Legal Business Name): MRS. CRYSTAL CHARLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 WEST RIVER DR NE
BELMONT MI
49306-8806
US

IV. Provider business mailing address

5841 WEST RIVER DR NE
BELMONT MI
49306-8806
US

V. Phone/Fax

Practice location:
  • Phone: 267-980-1221
  • Fax:
Mailing address:
  • Phone: 267-980-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC008947
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: