Healthcare Provider Details

I. General information

NPI: 1245195643
Provider Name (Legal Business Name): KRYSTAL MARIE TREADWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 392
TRAVERSE CITY MI
49685-0392
US

IV. Provider business mailing address

103B W CHERRY CREEK RD
MIO MI
48647-9378
US

V. Phone/Fax

Practice location:
  • Phone: 231-268-0007
  • Fax: 231-525-3170
Mailing address:
  • Phone: 989-390-6297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: