Provider Demographics
NPI:1720596430
Name:COLE, CRYSTAL LYNN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:COLE
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 1:15 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MA
Mailing Address - Zip Code:01749-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 MYSTIC LAKE DR APT 2
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-2319
Practice Address - Country:US
Practice Address - Phone:781-697-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
MALABA1000741103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No252Y00000XAgenciesEarly Intervention Provider Agency