Provider Demographics
NPI:1063088706
Name:SMALL, CRYSTAL THERESA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:THERESA
Last Name:SMALL
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 1:9200 EDWARDS WAY APT 317
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3456
Mailing Address - Country:US
Mailing Address - Phone:301-830-0887
Mailing Address - Fax:
Practice Address - Street 1:9500 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-3701
Practice Address - Country:US
Practice Address - Phone:202-831-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP8829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health