Healthcare Provider Details

I. General information

NPI: 1912250895
Provider Name (Legal Business Name): COLLEEN KRYSTYNIAK R.N. M.S. MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 05/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 TOWN LINE RD
LANCASTER NY
14086-9614
US

IV. Provider business mailing address

370 TOWN LINE RD
LANCASTER NY
14086-9614
US

V. Phone/Fax

Practice location:
  • Phone: 716-684-2962
  • Fax:
Mailing address:
  • Phone: 716-684-2962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18 006054
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number450781-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: