Healthcare Provider Details

I. General information

NPI: 1467068262
Provider Name (Legal Business Name): A CRYSTAL MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 EXECUTIVE PARK DR STE 310
CINCINNATI OH
45241-4015
US

IV. Provider business mailing address

PO BOX 1441
WEST CHESTER OH
45071-1441
US

V. Phone/Fax

Practice location:
  • Phone: 513-923-6336
  • Fax: 562-261-1296
Mailing address:
  • Phone: 513-923-6336
  • Fax: 562-261-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: CRYSTAL FARRELL
Title or Position: OWNER
Credential: MSN, CNP
Phone: 513-923-6336