Provider Demographics
NPI:1205426590
Name:HEAD, CHRYSTYNA MICHELLE
Entity type:Individual
Prefix:
First Name:CHRYSTYNA
Middle Name:MICHELLE
Last Name:HEAD
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 1:23300 GREENFIELD RD STE 122
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-8408
Mailing Address - Country:US
Mailing Address - Phone:248-968-9508
Mailing Address - Fax:248-968-9516
Practice Address - Street 1:23300 GREENFIELD RD STE 122
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-8408
Practice Address - Country:US
Practice Address - Phone:248-968-9508
Practice Address - Fax:248-968-9516
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
MI68010989691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5839Medicaid