Healthcare Provider Details

I. General information

NPI: 1225784416
Provider Name (Legal Business Name): KRYSTAL ADAMS MACON BA, SST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 MOUNT ELLIOTT ST
DETROIT MI
48207-2311
US

IV. Provider business mailing address

19712 SANTA BARBARA DR
DETROIT MI
48221-1649
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone: 313-454-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6803088634
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: