Provider Demographics
NPI:1396106068
Name:HAVINS, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:HAVINS
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 1:2423 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1210
Mailing Address - Country:US
Mailing Address - Phone:260-745-9431
Mailing Address - Fax:260-745-0734
Practice Address - Street 1:2423 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1210
Practice Address - Country:US
Practice Address - Phone:260-745-9431
Practice Address - Fax:260-745-0734
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33007471A104100000X
IN34009649A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker