Provider Demographics
NPI:1013584580
Name:ADDISON, CRYSTAL CHARMAYNE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CHARMAYNE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:CHARMAYNE
Other - Last Name:TERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19142 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4144
Mailing Address - Country:US
Mailing Address - Phone:586-277-8423
Mailing Address - Fax:
Practice Address - Street 1:300 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2703
Practice Address - Country:US
Practice Address - Phone:313-867-8015
Practice Address - Fax:313-867-8040
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty