Provider Demographics
NPI:1912682352
Name:COLE, CRYSTINA MARIE
Entity Type:Individual
Prefix:
First Name:CRYSTINA
Middle Name:MARIE
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 1:65 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-3413
Mailing Address - Country:US
Mailing Address - Phone:567-220-7018
Mailing Address - Fax:567-220-7012
Practice Address - Street 1:65 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-3413
Practice Address - Country:US
Practice Address - Phone:567-220-7018
Practice Address - Fax:567-220-7012
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.183158101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)