Provider Demographics
NPI:1861215451
Name:BENNER, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BENNER
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 1:4845 BULLDOG WAY
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1466
Mailing Address - Country:US
Mailing Address - Phone:317-852-1060
Mailing Address - Fax:
Practice Address - Street 1:5565 N COUNTY ROAD 100 E
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:IN
Practice Address - Zip Code:46167-9433
Practice Address - Country:US
Practice Address - Phone:317-512-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39005174A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health