Provider Demographics
NPI:1104385574
Name:ANGERVILLE, CRYSTAL (LMHC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ANGERVILLE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 LINDEN BLVD APT E12
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3518
Mailing Address - Country:US
Mailing Address - Phone:631-793-8204
Mailing Address - Fax:
Practice Address - Street 1:151 LAWRENCE ST FL 4
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5240
Practice Address - Country:US
Practice Address - Phone:917-623-6801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009400OtherDEPARTMENT OF THE PROFESSIONS