MEDICARE: CRYSTAL CLEAR COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1184481194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL CLEAR COUNSELING

Provider Business Mailing Address
First Line	:	502 LUMBER ST
Second Line	:
City	:	NICHOLS
State	:	SC
Zip	:	29581-5074
Country	:	US
Telephone Number	:	508-254-0066
Fax Number	:	866-220-0907

Provider Business Practice Location Address
First Line	:	1500 HIGHWAY 17 N STE 201
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6078
Country	:	US
Telephone Number	:	508-254-0066
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LOREN MALKASIAN
Credential	:	PSY.D
Telephone Number	:	508-254-0066

Provider Enumeration Date	:	03/05/2024
Last Update Date	:	03/05/2024

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