Provider Demographics
NPI:1245548080
Name:MOORE, CRYSTAL DEA (PHD, MSW, MA)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:DEA
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, MSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1716
Mailing Address - Country:US
Mailing Address - Phone:518-727-3401
Mailing Address - Fax:518-453-9436
Practice Address - Street 1:902 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1716
Practice Address - Country:US
Practice Address - Phone:518-727-3401
Practice Address - Fax:518-453-9436
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077736-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical