Provider Demographics
NPI:1891115184
Name:AMICK, CRYSTAL AMBER LYNN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMBER LYNN
Last Name:AMICK
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 1:13083 HILCORTE LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-3704
Mailing Address - Country:US
Mailing Address - Phone:760-646-5410
Mailing Address - Fax:
Practice Address - Street 1:16519 VICTOR ST STE 421
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3935
Practice Address - Country:US
Practice Address - Phone:442-242-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 390200000X
CALMFT107398106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program