Provider Demographics
NPI:1477999217
Name:CLEMONS, CRYSTAL
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:CLEMONS
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 1:175 W 90TH ST
Mailing Address - Street 2:SUITE 12C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1214
Mailing Address - Country:US
Mailing Address - Phone:212-769-8737
Mailing Address - Fax:
Practice Address - Street 1:175 W 90TH ST
Practice Address - Street 2:SUITE 12C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1214
Practice Address - Country:US
Practice Address - Phone:212-769-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency