Provider Demographics
NPI:1457038291
Name:QUIST, CRYSTAL (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:QUIST
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BEHAVIOR TECHNICIAN
Mailing Address - Street 1:19 NIZAM DR
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-4017
Mailing Address - Country:US
Mailing Address - Phone:508-615-6078
Mailing Address - Fax:
Practice Address - Street 1:19 NIZAM DR
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-4017
Practice Address - Country:US
Practice Address - Phone:508-615-6078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-22-243888106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician