Healthcare Provider Details

I. General information

NPI: 1689356495
Provider Name (Legal Business Name): CRYSTAL ANN BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COMMUNITY COUNSELING EL DORADO

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 CHAMPAGNOLLE RD
EL DORADO AR
71730-4735
US

IV. Provider business mailing address

709 CHAMPAGNOLLE RD
EL DORADO AR
71730-4735
US

V. Phone/Fax

Practice location:
  • Phone: 937-510-6317
  • Fax:
Mailing address:
  • Phone: 937-510-6317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13103-C
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number56355
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: