Provider Demographics
NPI:1952016115
Name:ANDERSON, CRYSTAL LYNN (QMHA-R)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 OAK ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4019
Mailing Address - Country:US
Mailing Address - Phone:503-585-4949
Mailing Address - Fax:
Practice Address - Street 1:1118 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4019
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-4489171M00000X
OR22-CRM-946175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist