Provider Demographics
NPI:1023827482
Name:DOUGLAS, CRYSTAL (LSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2501
Mailing Address - Country:US
Mailing Address - Phone:208-816-0656
Mailing Address - Fax:
Practice Address - Street 1:1370 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2332
Practice Address - Country:US
Practice Address - Phone:509-758-2568
Practice Address - Fax:509-758-3413
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-41198104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker