Provider Demographics
NPI:1750127544
Name:VANDEVENTER, CRYSTAL DIAMOND
Entity type:Individual
Prefix:PROF
First Name:CRYSTAL
Middle Name:DIAMOND
Last Name:VANDEVENTER
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 1:18103 CEDAR ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-9583
Mailing Address - Country:US
Mailing Address - Phone:313-585-1134
Mailing Address - Fax:
Practice Address - Street 1:18103 CEDAR ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-9583
Practice Address - Country:US
Practice Address - Phone:313-585-1134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician