Provider Demographics
NPI:1881122406
Name:CHURCH, CRYSTAL ANN
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-6871
Mailing Address - Country:US
Mailing Address - Phone:304-822-6009
Mailing Address - Fax:
Practice Address - Street 1:200 GLENN ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2573
Practice Address - Country:US
Practice Address - Phone:240-580-1919
Practice Address - Fax:240-362-7409
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP7406101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional