Provider Demographics
NPI:1407030521
Name:JUSTICE, CRYSTAL NICOLE (LICSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 4TH ST
Mailing Address - Street 2:APT73D
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3764
Mailing Address - Country:US
Mailing Address - Phone:240-280-1483
Mailing Address - Fax:
Practice Address - Street 1:14800 4TH ST
Practice Address - Street 2:APT73D
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3764
Practice Address - Country:US
Practice Address - Phone:240-280-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500784811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical