Provider Demographics
NPI:1336763630
Name:RUTHERFORD, CRYSTAL LYNN (CDCA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WHITNEY DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-8402
Mailing Address - Country:US
Mailing Address - Phone:843-503-6271
Mailing Address - Fax:
Practice Address - Street 1:1823 EDEN RD
Practice Address - Street 2:
Practice Address - City:HAMERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45130-9720
Practice Address - Country:US
Practice Address - Phone:513-667-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171898101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)