Provider Demographics
NPI:1790029114
Name:MCCORMICK, CRYSTAL DEVON (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DEVON
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 AIRPORT WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4054
Mailing Address - Country:US
Mailing Address - Phone:907-750-7169
Mailing Address - Fax:907-490-4469
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4054
Practice Address - Country:US
Practice Address - Phone:907-590-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional