Provider Demographics
NPI:1932479045
Name:CRYSTAL E.NICKERSON, LLC
Entity Type:Organization
Organization Name:CRYSTAL E.NICKERSON, LLC
Other - Org Name:CHOICE BEHAVIORAL HEALTH & CONSULTATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:EYVETTE
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:336-617-0764
Mailing Address - Street 1:2302 W MEADOWVIEW RD
Mailing Address - Street 2:SUITE 228, BOX 24
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3721
Mailing Address - Country:US
Mailing Address - Phone:336-617-0764
Mailing Address - Fax:336-617-0964
Practice Address - Street 1:2302 W MEADOWVIEW RD
Practice Address - Street 2:SUITE 228, BOX 24
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3721
Practice Address - Country:US
Practice Address - Phone:336-617-0764
Practice Address - Fax:336-617-0964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418853Medicaid
NC8702219Medicaid