Provider Demographics
NPI:1669071213
Name:KISSELBURGH, CRYSTAL REANEE (MA, LAC, LPCC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:REANEE
Last Name:KISSELBURGH
Suffix:
Gender:F
Credentials:MA, LAC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 BROKEN SPOKE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-6981
Mailing Address - Country:US
Mailing Address - Phone:970-779-7824
Mailing Address - Fax:
Practice Address - Street 1:2956 NORTH AVE STE 1
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-3919
Practice Address - Country:US
Practice Address - Phone:970-208-1103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0026958101YM0800X
COACD.0001546101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty