Provider Demographics
NPI:1376286716
Name:GEFFRARD, CRYSTAL TAISHA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:TAISHA
Last Name:GEFFRARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 CYPRESS GARDENS LOOP UNIT 7304
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-7077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3880 COLONIAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1062
Practice Address - Country:US
Practice Address - Phone:239-351-3715
Practice Address - Fax:239-310-2046
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113749000Medicaid