Provider Demographics
NPI:1104614130
Name:RYAN, CRYSTAL (GED)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:RYAN
Suffix:
Gender:
Credentials:GED
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GED
Mailing Address - Street 1:PO BOX G
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-0167
Mailing Address - Country:US
Mailing Address - Phone:802-728-4466
Mailing Address - Fax:802-728-4197
Practice Address - Street 1:35 AYERS BROOK RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1040
Practice Address - Country:US
Practice Address - Phone:802-728-4466
Practice Address - Fax:802-728-4197
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator