Provider Demographics
NPI:1669242129
Name:MACIAS, CRYSTAL (QMHA-R, PHN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:QMHA-R, PHN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:EHRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHA-R, CADC-R, PHN
Mailing Address - Street 1:63158 DESCHUTES MARKET RD
Mailing Address - Street 2:337
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-2973
Mailing Address - Country:US
Mailing Address - Phone:458-600-8552
Mailing Address - Fax:
Practice Address - Street 1:63158 DESCHUTES MARKET RD
Practice Address - Street 2:337
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2973
Practice Address - Country:US
Practice Address - Phone:458-600-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-3590101YA0400X
OR23-QMHA-R-3759101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator