Healthcare Provider Details

I. General information

NPI: 1780209619
Provider Name (Legal Business Name): CRYSTAL SOM LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 BRIDGE ST
LOWELL MA
01852-1270
US

IV. Provider business mailing address

81 BRIDGE ST
LOWELL MA
01852-1270
US

V. Phone/Fax

Practice location:
  • Phone: 978-459-2306
  • Fax:
Mailing address:
  • Phone: 978-459-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10001617
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: