Provider Demographics
NPI:1992402705
Name:SMITH, CRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:SMITH
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 1:7029 MEISNER RD
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-3007
Mailing Address - Country:US
Mailing Address - Phone:810-479-7353
Mailing Address - Fax:
Practice Address - Street 1:195 HURON BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1421
Practice Address - Country:US
Practice Address - Phone:989-401-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician