Provider Demographics
NPI:1659133320
Name:SMITH, CRYSTAL AMBER (BA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMBER
Last Name:SMITH
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 E FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99217-7066
Mailing Address - Country:US
Mailing Address - Phone:509-475-6277
Mailing Address - Fax:
Practice Address - Street 1:1414 N VERCLER RD STE 2
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1092
Practice Address - Country:US
Practice Address - Phone:509-991-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT22-250198106S00000X
WACB61104446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician