Provider Demographics
NPI:1952146656
Name:STATOM, CRYSTAL DAWN (LPC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:STATOM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LYNNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1819
Mailing Address - Country:US
Mailing Address - Phone:518-903-0537
Mailing Address - Fax:
Practice Address - Street 1:970 LILA AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1683
Practice Address - Country:US
Practice Address - Phone:513-201-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406232101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor