Provider Demographics
NPI:1093531592
Name:DOUGLAS, CRYSTAL DARLENE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DARLENE
Last Name:DOUGLAS
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 1:626 BUCKEYE AVE
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1216
Mailing Address - Country:US
Mailing Address - Phone:937-710-6518
Mailing Address - Fax:
Practice Address - Street 1:626 BUCKEYE AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-1216
Practice Address - Country:US
Practice Address - Phone:937-710-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator