Provider Demographics
NPI:1871222018
Name:WIDMANN, CRYSTAL L (LPC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:L
Last Name:WIDMANN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 ROCK ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3740
Mailing Address - Country:US
Mailing Address - Phone:267-278-6251
Mailing Address - Fax:
Practice Address - Street 1:218 ROCK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3740
Practice Address - Country:US
Practice Address - Phone:267-278-6251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional