Provider Demographics
NPI:1730421371
Name:O'CONNELL, CRYSTAL RENEE-BEAVER (LMSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE-BEAVER
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:RENEE
Other - Last Name:BEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50430 SCHOOL HOUSE RD
Mailing Address - Street 2:100
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5910
Mailing Address - Country:US
Mailing Address - Phone:734-495-1722
Mailing Address - Fax:734-495-1722
Practice Address - Street 1:50430 SCHOOL HOUSE RD
Practice Address - Street 2:100
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5910
Practice Address - Country:US
Practice Address - Phone:734-495-1722
Practice Address - Fax:734-495-1722
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010942811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI213119549Medicaid