Basic Information
| Provider Information | |||||||||
| NPI: | 1578996534 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL ACADEMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 PHOENETIA AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331343312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055675881 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 PHOENETIA AVE | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331343312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055675881 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2013 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | MONTERROSO | ||||||||
| AuthorizedOfficialFirstName: | DAISY | ||||||||
| AuthorizedOfficialMiddleName: | MARGARITA | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 7867041485 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | B.S | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.