Provider Demographics
NPI:1457735524
Name:CARTER, KRYSTLE NICOLE (BA PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:NICOLE
Last Name:CARTER
Suffix:
Gender:F
Credentials:BA PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18505 MEYERS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1308
Mailing Address - Country:US
Mailing Address - Phone:313-463-1061
Mailing Address - Fax:
Practice Address - Street 1:2939 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:313-396-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator