Provider Demographics
NPI:1659870798
Name:JOHNSON, CRYSTAL ROSE (PSYD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W BELMONT AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4462
Mailing Address - Country:US
Mailing Address - Phone:773-844-2732
Mailing Address - Fax:
Practice Address - Street 1:715 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1422
Practice Address - Country:US
Practice Address - Phone:708-209-8987
Practice Address - Fax:708-434-5586
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009543103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical