Provider Demographics
NPI:1275008161
Name:NULL, KRYSTAL RENAY (LSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:RENAY
Last Name:NULL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S PLUM ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1631
Mailing Address - Country:US
Mailing Address - Phone:937-644-9192
Mailing Address - Fax:
Practice Address - Street 1:715 S PLUM ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1631
Practice Address - Country:US
Practice Address - Phone:937-644-9192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251B00000XAgenciesCase Management