Healthcare Provider Details

I. General information

NPI: 1609554765
Provider Name (Legal Business Name): CRYSTAL RAE NIELSEN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 LAKE EARL DR
CRESCENT CITY CA
95532-0002
US

IV. Provider business mailing address

5905 LAKE EARL DR
CRESCENT CITY CA
95532-0001
US

V. Phone/Fax

Practice location:
  • Phone: 707-954-6141
  • Fax:
Mailing address:
  • Phone: 707-465-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: