Provider Demographics
NPI:1174262984
Name:CHALICH, KRYSTLE (JD)
Entity Type:Individual
Prefix:PROF
First Name:KRYSTLE
Middle Name:
Last Name:CHALICH
Suffix:
Gender:F
Credentials:JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CAROLINE ST.
Mailing Address - Street 2:UNIT 2 SARIZEN
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-3338
Mailing Address - Country:US
Mailing Address - Phone:518-312-9899
Mailing Address - Fax:
Practice Address - Street 1:121 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-3338
Practice Address - Country:US
Practice Address - Phone:518-312-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
NY9063690022084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S2012OtherCONSOLIDATED HEALTH PLAN MAGNACARE
NYDBF40661JOtherCDPHP - MCO
NYBF40661J-00Medicaid