Provider Demographics
NPI:1225784416
Name:ADAMS MACON, KRYSTAL (BA, SST)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ADAMS MACON
Suffix:
Gender:F
Credentials:BA, SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19712 SANTA BARBARA DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1649
Mailing Address - Country:US
Mailing Address - Phone:313-454-8158
Mailing Address - Fax:
Practice Address - Street 1:3646 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2311
Practice Address - Country:US
Practice Address - Phone:313-331-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803088634171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator