Provider Demographics
NPI:1801981014
Name:BESAW, CRYSTAL D (MSE)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:D
Last Name:BESAW
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:DAHLBERG
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22308
Mailing Address - Street 2:300 CROOKS STREET
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2308
Mailing Address - Country:US
Mailing Address - Phone:920-436-6800
Mailing Address - Fax:920-432-5966
Practice Address - Street 1:300 CROOKS STREET
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI54OtherDPI