Provider Demographics
NPI:1619332863
Name:MARTIN, CRYSTAL DOMYNIQUE (MED)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DOMYNIQUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DOMYNIQUE
Other - Last Name:PINEIRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:513 CANARY AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2747
Mailing Address - Country:US
Mailing Address - Phone:956-655-8987
Mailing Address - Fax:
Practice Address - Street 1:2009 N CONWAY AVE
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2965
Practice Address - Country:US
Practice Address - Phone:956-655-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72973101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional