Provider Demographics
NPI:1265262612
Name:WISS, CRYSTAL ROSE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:WISS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ROSE
Other - Last Name:HASKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0031
Mailing Address - Country:US
Mailing Address - Phone:541-967-3866
Mailing Address - Fax:541-812-8807
Practice Address - Street 1:1600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3109
Practice Address - Country:US
Practice Address - Phone:541-451-5932
Practice Address - Fax:541-812-8807
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8013101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional