Provider Demographics
NPI:1104083146
Name:JOHN, CRYSTAL A (MSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:JOHN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17224 133RD AVE APT 2G
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3901
Mailing Address - Country:US
Mailing Address - Phone:718-949-7233
Mailing Address - Fax:718-626-0690
Practice Address - Street 1:9729 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2240
Practice Address - Country:US
Practice Address - Phone:718-896-3400
Practice Address - Fax:718-459-5621
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid