Provider Demographics
NPI:1679723241
Name:DILLARD, CRYSTAL L (PHD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:DILLARD
Suffix:
Gender:F
Credentials:PHD
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 11407 DRAWER 1492
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-1492
Mailing Address - Country:US
Mailing Address - Phone:205-939-9193
Mailing Address - Fax:205-939-9949
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:ACC 500
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-939-9193
Practice Address - Fax:205-939-9949
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1545103T00000X, 103TC0700X
TN2829103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-97317OtherBCBS
AL515-98119OtherFEDERAL BC
AL1679723241OtherTRICARE SOUTH
AL515-97316OtherBCBS
AL515-98120OtherFEDERAL BC
AL109018Medicaid
AL109021Medicaid