Provider Demographics
NPI:1720302904
Name:GREEN, CRYSTALIZ (MS)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTALIZ
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5945
Mailing Address - Country:US
Mailing Address - Phone:215-735-9379
Mailing Address - Fax:215-732-8199
Practice Address - Street 1:1235 PINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5945
Practice Address - Country:US
Practice Address - Phone:215-735-9379
Practice Address - Fax:215-732-8199
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional