Provider Demographics
NPI:1619286127
Name:HARRIS, CRYSTAL M
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:M
Last Name:HARRIS
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 1:26630 SUMPTER RD
Mailing Address - Street 2:
Mailing Address - City:SUMPTER TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-8805
Mailing Address - Country:US
Mailing Address - Phone:313-422-5551
Mailing Address - Fax:
Practice Address - Street 1:26630 SUMPTER RD
Practice Address - Street 2:
Practice Address - City:SUMPTER TWP
Practice Address - State:MI
Practice Address - Zip Code:48111
Practice Address - Country:US
Practice Address - Phone:313-422-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225800000X225800000X
MI4703117523164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist