Provider Demographics
NPI:1093345993
Name:COOK, CRYSTAL GAIL (LCDC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:COOK
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76374-0042
Mailing Address - Country:US
Mailing Address - Phone:940-867-9052
Mailing Address - Fax:
Practice Address - Street 1:35103 STATE HIGHWAY 79 S
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:TX
Practice Address - Zip Code:76374-2505
Practice Address - Country:US
Practice Address - Phone:940-867-9052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15090101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty