Provider Demographics
NPI:1578216487
Name:DAVISON, CRYSTAL ROSE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:DAVISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2299
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2299
Mailing Address - Country:US
Mailing Address - Phone:307-734-6040
Mailing Address - Fax:
Practice Address - Street 1:89 N MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5164
Practice Address - Country:US
Practice Address - Phone:307-734-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health