Healthcare Provider Details

I. General information

NPI: 1609798933
Provider Name (Legal Business Name): THE KRYSTAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 DEWEY AVE
ELYRIA OH
44035-3553
US

IV. Provider business mailing address

625 DEWEY AVE
ELYRIA OH
44035-3553
US

V. Phone/Fax

Practice location:
  • Phone: 216-242-8152
  • Fax:
Mailing address:
  • Phone: 216-242-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL BRANTLEY
Title or Position: EXECUTIVE DIRECTOR/PRESIDENT
Credential:
Phone: 216-242-8152