Provider Demographics
NPI:1982423596
Name:CERTAIN, CRYSTAL (LAC)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:CERTAIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 PINEYWOODS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2517
Mailing Address - Country:US
Mailing Address - Phone:501-551-5408
Mailing Address - Fax:
Practice Address - Street 1:109 PINEYWOODS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-2517
Practice Address - Country:US
Practice Address - Phone:501-551-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2408006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health