Provider Demographics
NPI:1891495818
Name:O'GORMAN, CRYSTAL DAWN (LMFTA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7751 BALLANTYNE COMMONS PKWY # 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2442
Mailing Address - Country:US
Mailing Address - Phone:704-626-6550
Mailing Address - Fax:
Practice Address - Street 1:7751 BALLANTYNE COMMONS PKWY # 102
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2442
Practice Address - Country:US
Practice Address - Phone:704-626-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12507A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist