Provider Demographics
NPI:1831601061
Name:HARRIS, CRYSTAL L (MSSA, LSW,LICDC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:HARRIS
Suffix:
Gender:F
Credentials:MSSA, LSW,LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11906 SUMMERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5059
Mailing Address - Country:US
Mailing Address - Phone:216-450-9526
Mailing Address - Fax:
Practice Address - Street 1:4269 PEARL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4234
Practice Address - Country:US
Practice Address - Phone:216-431-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1701473101YA0400X
OH130671101YA0400X
OHS.1701473104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker