Provider Demographics
NPI:1891434932
Name:CRUICKSHANK, KERYL MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KERYL
Middle Name:MARIE
Last Name:CRUICKSHANK
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 1:636 RED FERN RD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5471
Mailing Address - Country:US
Mailing Address - Phone:850-279-6736
Mailing Address - Fax:
Practice Address - Street 1:636 RED FERN RD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5471
Practice Address - Country:US
Practice Address - Phone:850-279-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW145281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical