Provider Demographics
NPI:1225040553
Name:ROARK, CRYSTAL ANNETTE (BS, CM-A)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANNETTE
Last Name:ROARK
Suffix:
Gender:F
Credentials:BS, CM-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4415
Mailing Address - Country:US
Mailing Address - Phone:580-323-6021
Mailing Address - Fax:580-323-9375
Practice Address - Street 1:94 N 31ST ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9116
Practice Address - Country:US
Practice Address - Phone:580-323-6021
Practice Address - Fax:580-323-9375
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health