Provider Demographics
NPI:1588223184
Name:WITT, CRYSTAL MARIE
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:WITT
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 1:1177 S SILVERADO ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-0924
Mailing Address - Country:US
Mailing Address - Phone:602-492-2125
Mailing Address - Fax:
Practice Address - Street 1:7435 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-8337
Practice Address - Country:US
Practice Address - Phone:480-590-5293
Practice Address - Fax:480-564-1060
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15094101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLISAC-15094OtherLISAC