Provider Demographics
NPI:1508697954
Name:CISCO, CRYSTAL GAIL (CDC-A, PRS)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:CISCO
Suffix:
Gender:F
Credentials:CDC-A, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 EDGEWOOD DR APT A6
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1032
Mailing Address - Country:US
Mailing Address - Phone:537-825-2195
Mailing Address - Fax:419-771-1051
Practice Address - Street 1:123 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1707
Practice Address - Country:US
Practice Address - Phone:419-771-1050
Practice Address - Fax:419-771-1051
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH004930175T00000X
OH000741747101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist