Provider Demographics
NPI:1669816112
Name:MCCLAIN, CRYSTAL A (CAPSW)
Entity Type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:A
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:CAPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2020
Mailing Address - Country:US
Mailing Address - Phone:414-915-2637
Mailing Address - Fax:414-810-1567
Practice Address - Street 1:2518 N 17TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-2020
Practice Address - Country:US
Practice Address - Phone:414-915-2637
Practice Address - Fax:414-810-1567
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI128168-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker