Provider Demographics
NPI:1407225642
Name:LEWIS, CRYSTAL ANN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LEDFORD
Mailing Address - Street 1:1070 W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9613
Mailing Address - Country:US
Mailing Address - Phone:989-202-4900
Mailing Address - Fax:
Practice Address - Street 1:342 W. CEDAR ST
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:49624
Practice Address - Country:US
Practice Address - Phone:989-202-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker