Healthcare Provider Details

I. General information

NPI: 1750818225
Provider Name (Legal Business Name): C CRYSTAL PSYCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 MACK RD
FAIRFIELD OH
45014-5130
US

IV. Provider business mailing address

2810 MACK RD
FAIRFIELD OH
45014-5130
US

V. Phone/Fax

Practice location:
  • Phone: 314-308-7772
  • Fax: 314-308-7772
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHANA D CRYSTAL
Title or Position: OWNER
Credential: PSYD, EDS
Phone: 314-308-7772