1114366531 NPI number — CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES

Table of content: (NPI 1114366531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114366531 NPI number — CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114366531
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4304A E CENTRAL TEXAS EXPY STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76543-7308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-275-0937
Provider Business Mailing Address Fax Number:
708-310-6057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 RIDGE ROAD
Provider Second Line Business Practice Location Address:
UNIT 104
Provider Business Practice Location Address City Name:
HOMEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60430-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-275-0937
Provider Business Practice Location Address Fax Number:
815-521-1889
Provider Enumeration Date:
06/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FIELDS
Authorized Official First Name:
TAMARA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-275-0937

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149.014385 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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