Provider Demographics
NPI:1952853814
Name:CRYSTAL, TINA M (PSYD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CRYSTAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:SANDORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:10 FOREST PARK DR FL 1
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1499
Mailing Address - Country:US
Mailing Address - Phone:860-269-7813
Mailing Address - Fax:
Practice Address - Street 1:10 FOREST PARK DR FL 1
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1499
Practice Address - Country:US
Practice Address - Phone:860-269-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003623103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical