Provider Demographics
NPI:1790256790
Name:LEATCH GEORGE, CRYSTAL NICOLE (LCSW, RN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:LEATCH GEORGE
Suffix:
Gender:F
Credentials:LCSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 SIX PINES DR APT 511
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2596
Mailing Address - Country:US
Mailing Address - Phone:832-457-2484
Mailing Address - Fax:
Practice Address - Street 1:10200 SIX PINES DR APT 511
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-2596
Practice Address - Country:US
Practice Address - Phone:832-457-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX502331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical