Provider Demographics
NPI:1790374650
Name:TELLOR, CRYSTAL DAWN
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:TELLOR
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 1:338 BROADWAY ST # 301
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-7331
Mailing Address - Country:US
Mailing Address - Phone:573-225-6678
Mailing Address - Fax:
Practice Address - Street 1:338 BROADWAY ST # 301
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7331
Practice Address - Country:US
Practice Address - Phone:573-225-6678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician