Provider Demographics
NPI:1356884001
Name:CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES INC
Entity type:Organization
Organization Name:CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-275-0937
Mailing Address - Street 1:4304A E CENTRAL TEXAS EXPY STE A
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-7308
Mailing Address - Country:US
Mailing Address - Phone:708-275-0937
Mailing Address - Fax:708-310-6057
Practice Address - Street 1:4304A E CENTRAL TEXAS EXPY STE A
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-7308
Practice Address - Country:US
Practice Address - Phone:708-275-0937
Practice Address - Fax:708-310-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX585691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342420202Medicaid
TX342420203Medicaid