Provider Demographics
NPI:1053169938
Name:UDO, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:UDO
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 1:2851 N OAKLAND FOREST DR APT 108
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6487
Mailing Address - Country:US
Mailing Address - Phone:516-661-9162
Mailing Address - Fax:
Practice Address - Street 1:7301A W PALMETTO PARK RD STE 100C
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3403
Practice Address - Country:US
Practice Address - Phone:954-248-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-345661106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician