Provider Demographics
NPI:1306331541
Name:MARTIN, CRYSTALROSE
Entity type:Individual
Prefix:
First Name:CRYSTALROSE
Middle Name:
Last Name:MARTIN
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 1:627 BUCKLER AVE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-3338
Mailing Address - Country:US
Mailing Address - Phone:919-729-4390
Mailing Address - Fax:
Practice Address - Street 1:627 BUCKLER AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:NC
Practice Address - Zip Code:28315-3338
Practice Address - Country:US
Practice Address - Phone:919-729-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician