Basic Information
| Provider Information | |||||||||
| NPI: | 1003010091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRYSTAL | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MDIV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 HILLCREST AVE | ||||||||
| Address2: | |||||||||
| City: | SUMMIT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9084036597 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738220707 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YP1600X | X | Behavioral Health & Social Service Providers | Counselor | Pastoral | 102L00000X | 19000051 | NY | X | Behavioral Health & Social Service Providers | Psychoanalyst |
No ID Information.