Healthcare Provider Details

I. General information

NPI: 1144048828
Provider Name (Legal Business Name): CRYSTAL EVANS NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 S HILLS DR
CLEVELAND OH
44109-4603
US

IV. Provider business mailing address

4747 S HILLS DR
CLEVELAND OH
44109-4603
US

V. Phone/Fax

Practice location:
  • Phone: 216-338-5779
  • Fax:
Mailing address:
  • Phone: 216-338-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberA3453317
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: