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General NPI Number Information
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NPI Number | 1174704068
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Entity Type | Organization
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Legal Business Name | CROSSROADS PSYCHOTHERAPY PC
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Dates
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Enumeration Date | 11/19/2007
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Last Update Date | 05/02/2013
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Provider Practice Location Address
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Address Line | 432 WILDWOOD AVE
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City | JACKSON
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State | MI
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Zip | 49201-1148
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Country | US
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Telephone | 517-787-2251
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Fax | 517-787-2879
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Provider Business Mailing Address
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Address Line | 432 WILDWOOD AVE
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City | JACKSON
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State | MI
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Zip | 49201-1148
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Country | US
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Telephone | 517-787-2251
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Fax | 517-787-2879
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. DAVID RALPH KRAJEWSKI
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Credential | LMSW
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Telephone | 517-787-2251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6801057593
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License Number State | MI
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