Provider Demographics
NPI:1558850693
Name:POMBERT, CRYSTAL DANAE' (RBT)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DANAE'
Last Name:POMBERT
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:GRANT PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60940-0194
Mailing Address - Country:US
Mailing Address - Phone:815-662-8209
Mailing Address - Fax:
Practice Address - Street 1:210 N PRAIRIE
Practice Address - Street 2:
Practice Address - City:GRANT PARK
Practice Address - State:IL
Practice Address - Zip Code:60940-7154
Practice Address - Country:US
Practice Address - Phone:815-662-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician