Basic Information
| Provider Information | |||||||||
| NPI: | 1902157837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15945 CANAL ROAD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864162300 | ||||||||
| FaxNumber: | 5864162311 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 S MONROE ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481612469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342403850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2012 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401014693 | MI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 6401014693 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | SA0580017 | 05 | MI | MEDICAID |