Provider Demographics
NPI:1215571088
Name:BAZEMORE, CRYSTAL MARIE (CDCA)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:BAZEMORE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5664 DASHSHUND CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-7506
Mailing Address - Country:US
Mailing Address - Phone:614-962-0842
Mailing Address - Fax:
Practice Address - Street 1:1755 LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-3108
Practice Address - Country:US
Practice Address - Phone:614-610-9023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168708101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty