Provider Demographics
NPI:1073189833
Name:DESTOUCHE, CRYSTAL RUBY
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RUBY
Last Name:DESTOUCHE
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 1:9114 MERRICK BLVD FL 6
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5363
Mailing Address - Country:US
Mailing Address - Phone:718-262-8190
Mailing Address - Fax:
Practice Address - Street 1:9114 MERRICK BLVD FL 6
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5363
Practice Address - Country:US
Practice Address - Phone:718-674-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor