Provider Demographics
NPI:1356625081
Name:LIM, CRYSTAL STACK (PHD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:STACK
Last Name:LIM
Suffix:
Gender:F
Credentials:PHD
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 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:ONE HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-1561
Practice Address - Fax:573-884-1889
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022015232103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05908053Medicaid
MO490113666Medicaid