MEDICARE: CRYSTAL DIANE COLUMBIA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	174H00000X	Health Educator
2	106S00000X	Behavior Technician
3	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1811676752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DIANE COLUMBIA

Provider Business Mailing Address
First Line	:	1171 BRIDGETON RD
Second Line	:
City	:	FAWN GROVE
State	:	PA
Zip	:	17321-9320
Country	:	US
Telephone Number	:	443-417-4800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1171 BRIDGETON RD
Second Line	:
City	:	FAWN GROVE
State	:	PA
Zip	:	17321-9320
Country	:	US
Telephone Number	:	443-417-4800
Fax Number	:

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

Provider Enumeration Date	:	07/17/2023
Last Update Date	:	07/17/2023

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Directions to “ CRYSTAL DIANE COLUMBIA ” Practice Location

Language	Start Address	Practice Location

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