Provider Demographics
NPI:1053827550
Name:WIECZOREK, CRYSTAL SUNSHINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:SUNSHINE
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 5024
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-5024
Mailing Address - Country:US
Mailing Address - Phone:315-226-6228
Mailing Address - Fax:
Practice Address - Street 1:UNIT 5024
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-5024
Practice Address - Country:US
Practice Address - Phone:315-226-6228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105291-1104100000X
HILCSW-51371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker