Provider Demographics
NPI:1114535150
Name:GREEN, CRYSTAL LOUISE
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:LOUISE
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19206 21ST ST SW
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9280
Mailing Address - Country:US
Mailing Address - Phone:125-329-2888
Mailing Address - Fax:
Practice Address - Street 1:307 W COTA ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2265
Practice Address - Country:US
Practice Address - Phone:360-839-2822
Practice Address - Fax:360-839-2822
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA100000034753Medicaid