Provider Demographics
NPI:1407355266
Name:CRYSTAL, CHANA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHANA
Middle Name:
Last Name:CRYSTAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 MACK RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5130
Mailing Address - Country:US
Mailing Address - Phone:513-666-0816
Mailing Address - Fax:
Practice Address - Street 1:2812 MACK RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5130
Practice Address - Country:US
Practice Address - Phone:513-666-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7554103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCS180030014OtherCARESOURCE