Basic Information
| Provider Information | |||||||||
| NPI: | 1427548056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | LYNNISE | ||||||||
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| Credential: | B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 N GROESBECK HWY | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480431562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866270024 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2925 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2018 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6803087084 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 171M00000X | 6803087084 | MI | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.