Provider Demographics
NPI:1871250761
Name:OUTLAW, CRYSTAL EVE
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:EVE
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 FAST PARK DR STE 301
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4853
Mailing Address - Country:US
Mailing Address - Phone:919-980-5025
Mailing Address - Fax:
Practice Address - Street 1:8801 FAST PARK DR STE 301
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4853
Practice Address - Country:US
Practice Address - Phone:412-913-0728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27162101YA0400X
NCC0162961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)