Provider Demographics
NPI:1356581227
Name:LIDDYCOAT, CRYSTAL ANN BOSTOW (MA, LAC, LPC)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN BOSTOW
Last Name:LIDDYCOAT
Suffix:
Gender:F
Credentials:MA, LAC, LPC
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:BOSTOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2910 38TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7061
Mailing Address - Country:US
Mailing Address - Phone:530-799-0499
Mailing Address - Fax:
Practice Address - Street 1:2910 38TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7061
Practice Address - Country:US
Practice Address - Phone:530-799-0499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1596101YA0400X
ND621-12-15-08101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)