Provider Demographics
NPI:1306334602
Name:CHESTER, CRYSTAL LYNETTE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNETTE
Last Name:CHESTER
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 1:10514 RACETRACK RD
Mailing Address - Street 2:SUIT G
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10514 RACETRACK RD
Practice Address - Street 2:SUIT G
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3241
Practice Address - Country:US
Practice Address - Phone:410-973-2301
Practice Address - Fax:410-973-2305
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid