Healthcare Provider Details

I. General information

NPI: 1891115184
Provider Name (Legal Business Name): CRYSTAL AMBER LYNN AMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16519 VICTOR ST STE 421
VICTORVILLE CA
92395-3935
US

IV. Provider business mailing address

13083 HILCORTE LN
VICTORVILLE CA
92394-3704
US

V. Phone/Fax

Practice location:
  • Phone: 442-242-4325
  • Fax:
Mailing address:
  • Phone: 760-646-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT107398
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: