MEDICARE: CRYSTAL BIVENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	APP-000465259	OH

General Provider Information

NPI Number	:	1316613995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL BIVENS

Provider Business Mailing Address
First Line	:	1008 YELLOWSTONE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1423
Country	:	US
Telephone Number	:	216-240-8034
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 YELLOWSTONE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-1423
Country	:	US
Telephone Number	:	216-240-8034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	08/23/2021

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Directions to “ CRYSTAL BIVENS ” Practice Location

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