Provider Demographics
NPI:1356907422
Name:EDWARDS, CRYSTAL SUE (LMSW)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SUE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:SUE
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 E SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 E SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-864-0560
Practice Address - Fax:907-864-0564
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1518691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical