Provider Demographics
NPI:1982008835
Name:GREEN-RANDLE, CRYSTAL B
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:B
Last Name:GREEN-RANDLE
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 1:1031 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1318
Mailing Address - Country:US
Mailing Address - Phone:443-763-3718
Mailing Address - Fax:410-744-7309
Practice Address - Street 1:1031 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1318
Practice Address - Country:US
Practice Address - Phone:443-763-3718
Practice Address - Fax:410-744-7309
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7361101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional