Provider Demographics
NPI:1821599788
Name:CRYSTAL WATERS LICENSED CLINICAL SOCIAL WORK, PLLC
Entity type:Organization
Organization Name:CRYSTAL WATERS LICENSED CLINICAL SOCIAL WORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:607-654-9872
Mailing Address - Street 1:62 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:NY
Mailing Address - Zip Code:14801-1319
Mailing Address - Country:US
Mailing Address - Phone:607-654-9872
Mailing Address - Fax:
Practice Address - Street 1:83 W PULTENEY ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2213
Practice Address - Country:US
Practice Address - Phone:607-654-9872
Practice Address - Fax:607-973-2727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080623251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health