Provider Demographics
NPI:1376314989
Name:LAIKHRAM, CRYSTAL LEE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:LAIKHRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LEE
Other - Last Name:LAIKHRAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1266 OLMSTEAD AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4620
Mailing Address - Country:US
Mailing Address - Phone:646-548-7127
Mailing Address - Fax:
Practice Address - Street 1:100 DUFFY AVE
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3636
Practice Address - Country:US
Practice Address - Phone:631-600-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
NY122719171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker