Provider Demographics
NPI:1427300516
Name:DAVIS, CRYSTAL MARY
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARY
Last Name:DAVIS
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 1:15 ADNA RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-2719
Mailing Address - Country:US
Mailing Address - Phone:860-502-4481
Mailing Address - Fax:
Practice Address - Street 1:15 ADNA RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-2719
Practice Address - Country:US
Practice Address - Phone:860-502-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC07011002543101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool