Provider Demographics
NPI:1003010091
Name:CHRYSTAL, SUSAN P (MDIV)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:P
Last Name:CHRYSTAL
Suffix:
Gender:F
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901
Mailing Address - Country:US
Mailing Address - Phone:908-403-6597
Mailing Address - Fax:
Practice Address - Street 1:16 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940
Practice Address - Country:US
Practice Address - Phone:973-822-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
NY19000051102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Not Answered102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst