Provider Demographics
NPI:1811430325
Name:MCCUBBIN, CRYSTAL (MA, LPC, LAC, NCC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MCCUBBIN
Suffix:
Gender:F
Credentials:MA, LPC, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 IMPERIAL ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80516-9409
Mailing Address - Country:US
Mailing Address - Phone:719-924-5549
Mailing Address - Fax:
Practice Address - Street 1:3763 IMPERIAL ST UNIT B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80516-9409
Practice Address - Country:US
Practice Address - Phone:719-924-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 101YP2500X, 171W00000X
CONLC 0105277101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171W00000XOther Service ProvidersContractor