=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871401067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRYSTAL MICHAEL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2026
-----------------------------------------------------
Last Update Date | 08/31/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3830 W 95TH ST STE 106
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-264-9012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9407 S AVERS AVE
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-264-9012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC NURSEPRACTITIONER
-----------------------------------------------------
Name | LISA L WRIGHT
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 708-264-9012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------