Provider Demographics
NPI:1720758626
Name:KING, CRYSTAL ANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANNE
Last Name:KING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-014 WAIHONU ST APT E304
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-3302
Mailing Address - Country:US
Mailing Address - Phone:509-637-3960
Mailing Address - Fax:
Practice Address - Street 1:103 BODIN CIRCLE
Practice Address - Street 2:TRAVIS AFB
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94535
Practice Address - Country:US
Practice Address - Phone:707-423-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-18793104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker