MEDICARE: CRYSTAL RENEE BURNETT BSW

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1982264495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL RENEE BURNETT BSW

Provider Business Mailing Address
First Line	:	5897 CHRISTIE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-6238
Country	:	US
Telephone Number	:	616-323-7177
Fax Number	:

Provider Business Practice Location Address
First Line	:	5897 CHRISTIE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-6238
Country	:	US
Telephone Number	:	614-686-7177
Fax Number	:

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

Provider Enumeration Date	:	06/17/2019
Last Update Date	:	06/17/2019

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