Healthcare Provider Details

I. General information

NPI: 1003010091
Provider Name (Legal Business Name): SUSAN P CHRYSTAL MDIV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MADISON AVE
MADISON NJ
07940
US

IV. Provider business mailing address

129 HILLCREST AVE
SUMMIT NJ
07901
US

V. Phone/Fax

Practice location:
  • Phone: 973-822-0707
  • Fax:
Mailing address:
  • Phone: 908-403-6597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number19000051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: