Provider Demographics
NPI:1679111629
Name:MCDONALD, CRYSTAL ANGELIC
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANGELIC
Last Name:MCDONALD
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 1:3951 RUFINA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3585
Mailing Address - Country:US
Mailing Address - Phone:505-577-0003
Mailing Address - Fax:
Practice Address - Street 1:4001 OFFICE COURT DR STE 603
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4905
Practice Address - Country:US
Practice Address - Phone:505-577-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-10943101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health