Provider Demographics
NPI:1962629121
Name:DESJARDINS, CRYSTAL ELIZABETH
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELIZABETH
Last Name:DESJARDINS
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 1:12 GROVEMOUNT LANE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-4519
Mailing Address - Country:US
Mailing Address - Phone:207-786-5511
Mailing Address - Fax:
Practice Address - Street 1:102 CAMPUS AVENUE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240
Practice Address - Country:US
Practice Address - Phone:207-777-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist