Provider Demographics
NPI:1942763198
Name:BISSONETTE, CRYSTAL RENEE AMANDA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE AMANDA
Last Name:BISSONETTE
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 1:4440 SAN GABRIEL DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6418
Mailing Address - Country:US
Mailing Address - Phone:661-753-4955
Mailing Address - Fax:
Practice Address - Street 1:5375 RENO CORPORATE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2381
Practice Address - Country:US
Practice Address - Phone:775-376-9426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician