Provider Demographics
NPI:1063009702
Name:MCLENDON, CRYSTAL A
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:MCLENDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 CASTLEBAR ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2045
Mailing Address - Country:US
Mailing Address - Phone:330-430-9662
Mailing Address - Fax:
Practice Address - Street 1:4805 CASTLEBAR ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2045
Practice Address - Country:US
Practice Address - Phone:330-430-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2573442347C00000X, 372600000X, 3747P1801X, 253Z00000X, 172A00000X, 251X00000X, 343900000X
3747P1801X, 376J00000X, 172A00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No251X00000XAgenciesSupports Brokerage
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2573442OtherOHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES
OH0385197Medicaid