Provider Demographics
NPI:1689486870
Name:GARY, CRYSTAL (LSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GARY
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7031 CORPORATE WAY STE 103
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4262
Mailing Address - Country:US
Mailing Address - Phone:937-619-9089
Mailing Address - Fax:
Practice Address - Street 1:7031 CORPORATE WAY STE 103
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4262
Practice Address - Country:US
Practice Address - Phone:937-619-9089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802430104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker