1851504971 NPI number — CORNERSTONE PSYCHOLOGICAL SERVICSE

Table of content: DR. KRYSTAL LYNN MOORMAN PHARMD (NPI 1477755502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851504971 NPI number — CORNERSTONE PSYCHOLOGICAL SERVICSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE PSYCHOLOGICAL SERVICSE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851504971
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W LIBERTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44256-2217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-722-4166
Provider Business Mailing Address Fax Number:
330-725-5792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W LIBERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44256-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-722-4166
Provider Business Practice Location Address Fax Number:
330-725-5792
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTHEL
Authorized Official First Name:
VELMA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
330-722-4166

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0787420 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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