Provider Demographics
NPI:1619473857
Name:OERTLE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:OERTLE
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 1:750 BARNARD AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1830
Mailing Address - Country:US
Mailing Address - Phone:419-631-0259
Mailing Address - Fax:
Practice Address - Street 1:151 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2223
Practice Address - Country:US
Practice Address - Phone:419-774-9969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.166220101YA0400X
OHCDCA.170007101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)