Healthcare Provider Details

I. General information

NPI: 1629710918
Provider Name (Legal Business Name): CRYSTALENA OBERWEISER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 S ALAMOS PL
COLUMBIA MO
65201-9429
US

IV. Provider business mailing address

2400 N STALLINGS DR STE 408
NACOGDOCHES TX
75964-1222
US

V. Phone/Fax

Practice location:
  • Phone: 615-571-1621
  • Fax:
Mailing address:
  • Phone: 615-571-1621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number102543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: