Healthcare Provider Details

I. General information

NPI: 1518741966
Provider Name (Legal Business Name): CRYSTAL CREEK COUNSELING , PC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 COFFMAN ST STE 210
LONGMONT CO
80501-5445
US

IV. Provider business mailing address

PO BOX 94
GREEN MOUNTAIN FALLS CO
80819-0094
US

V. Phone/Fax

Practice location:
  • Phone: 719-686-6703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JERILYN L YINGLING
Title or Position: OWNER
Credential:
Phone: 719-686-6703