Healthcare Provider Details

I. General information

NPI: 1144512310
Provider Name (Legal Business Name): KRYSTAL L MARTIN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRYSTAL L PRESTON LSW

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 GRANVILLE ST
GAHANNA OH
43230-2990
US

IV. Provider business mailing address

338 GRANVILLE ST
GAHANNA OH
43230-2990
US

V. Phone/Fax

Practice location:
  • Phone: 614-475-7090
  • Fax: 614-475-5208
Mailing address:
  • Phone: 614-475-7090
  • Fax: 614-475-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1000293
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: