Healthcare Provider Details

I. General information

NPI: 1629441118
Provider Name (Legal Business Name): CRYSTAL YVETTE CUNNINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12561 WARDLINE RD
HAMMOND LA
70401
US

IV. Provider business mailing address

15043 WOODSTONE DR APT 187
HAMMOND LA
70401-1262
US

V. Phone/Fax

Practice location:
  • Phone: 985-551-5155
  • Fax:
Mailing address:
  • Phone: 225-614-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: