Provider Demographics
NPI:1972193266
Name:IRISH, CRYSTAL (LADAC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:IRISH
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX G
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-0167
Mailing Address - Country:US
Mailing Address - Phone:802-728-4466
Mailing Address - Fax:
Practice Address - Street 1:39 FOGG FARM RD
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JCT
Practice Address - State:VT
Practice Address - Zip Code:05088-0508
Practice Address - Country:US
Practice Address - Phone:802-295-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0134105101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)