Provider Demographics
NPI:1124553102
Name:CRYSTAL CREEK COUNSELING
Entity Type:Organization
Organization Name:CRYSTAL CREEK COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JERILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:YINGLING
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-686-6703
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:11120 PUEBLO AVE
Mailing Address - City:GREEN MOUNTAIN FALLS
Mailing Address - State:CO
Mailing Address - Zip Code:80819-0094
Mailing Address - Country:US
Mailing Address - Phone:719-640-5344
Mailing Address - Fax:
Practice Address - Street 1:400 W MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3144
Practice Address - Country:US
Practice Address - Phone:719-640-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0012668101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty