Healthcare Provider Details

I. General information

NPI: 1639563984
Provider Name (Legal Business Name): CRYSTAL LOUISE OLMSTEAD PCC#3819ANDLSW#21302
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 ARBOR BLVD.
DAYTON OH
45439-1521
US

IV. Provider business mailing address

2211 ARBOR BLVD.
DAYTON OH
45439-1521
US

V. Phone/Fax

Practice location:
  • Phone: 937-222-9481
  • Fax: 937-222-3710
Mailing address:
  • Phone: 937-222-9481
  • Fax: 937-222-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPCC#E318
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW#521302
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: