MEDICARE: MRS. CRYSTAL ANN BOSTOW LIDDYCOAT MA, LAC, LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1596	ND
2	101YM0800X	Mental Health Counselor	CP6207-R	NV
3	101YM0800X	Mental Health Counselor	621-12-15-08	ND

General Provider Information

NPI Number	:	1356581227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL ANN BOSTOW LIDDYCOAT MA, LAC, LPC

Provider Business Mailing Address
First Line	:	2910 38TH AVE S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-7061
Country	:	US
Telephone Number	:	530-799-0499
Fax Number	:

Provider Business Practice Location Address
First Line	:	726 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3304
Country	:	US
Telephone Number	:	971-500-2661
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2009
Last Update Date	:	01/13/2026

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