Provider Demographics
NPI:1720407398
Name:APPLEGATE, CRYSTAL JEAN (CMHC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JEAN
Last Name:APPLEGATE
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11251 S STATE ST
Mailing Address - Street 2:APT A207
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5163
Mailing Address - Country:US
Mailing Address - Phone:801-702-0427
Mailing Address - Fax:
Practice Address - Street 1:1196 W SOUTH JORDAN PKWY
Practice Address - Street 2:STE D
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4603
Practice Address - Country:US
Practice Address - Phone:801-702-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9838225-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health