Provider Demographics
NPI:1053860155
Name:COLLETTE, CRYSTAL DAWN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:COLLETTE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7247 MOOSE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:PORT LEYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13433-2204
Mailing Address - Country:US
Mailing Address - Phone:315-569-2386
Mailing Address - Fax:
Practice Address - Street 1:19 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1418
Practice Address - Country:US
Practice Address - Phone:315-853-6090
Practice Address - Fax:315-853-3190
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070761-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical