Provider Demographics
NPI:1760743017
Name:MOREA, KRYSTAL D (LGSW)
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:D
Last Name:MOREA
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 KATE WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6957
Mailing Address - Country:US
Mailing Address - Phone:410-848-2500
Mailing Address - Fax:410-876-3016
Practice Address - Street 1:59 KATE WAGNER RD
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6957
Practice Address - Country:US
Practice Address - Phone:410-848-2500
Practice Address - Fax:410-876-3016
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD176501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD420658400Medicaid