Provider Demographics
NPI:1699347245
Name:BUCHANAN, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:BUCHANAN
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 1:270 E HIGHLAND AVE APT 247
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6638
Mailing Address - Country:US
Mailing Address - Phone:414-395-0129
Mailing Address - Fax:
Practice Address - Street 1:270 E HIGHLAND AVE APT 247
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6638
Practice Address - Country:US
Practice Address - Phone:608-445-3649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8180-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional