Provider Demographics
NPI:1689040107
Name:DEVORE, KRYSTAL (LISW-S)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:DEVORE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 NORTHLAND DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3441
Mailing Address - Country:US
Mailing Address - Phone:330-723-9600
Mailing Address - Fax:330-722-1446
Practice Address - Street 1:246 NORTHLAND DR
Practice Address - Street 2:SUITE 140
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3441
Practice Address - Country:US
Practice Address - Phone:330-723-9600
Practice Address - Fax:330-722-1446
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.13021711041C0700X
OH13021711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0160326Medicaid