Provider Demographics
NPI:1558715391
Name:MAKING A DIFFERENCE SUPPORT SERVICES
Entity Type:Organization
Organization Name:MAKING A DIFFERENCE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-750-7169
Mailing Address - Street 1:1302 BENSHOOF DR
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-5666
Mailing Address - Country:US
Mailing Address - Phone:907-590-2100
Mailing Address - Fax:907-490-4469
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4054
Practice Address - Country:US
Practice Address - Phone:907-750-7169
Practice Address - Fax:907-490-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1634221Medicaid
AKK164905OtherMEDICARE PTAN