Provider Demographics
NPI:1417747197
Name:TAVERAS, CRYSTAL LEE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:TAVERAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3326
Mailing Address - Country:US
Mailing Address - Phone:774-315-4929
Mailing Address - Fax:
Practice Address - Street 1:591 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3326
Practice Address - Country:US
Practice Address - Phone:774-315-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty