Healthcare Provider Details

I. General information

NPI: 1669297420
Provider Name (Legal Business Name): CRYSTAL CUMMINS M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL SPEELMAN M.ED.

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N 5TH ST
BROCKTON MT
59213
US

IV. Provider business mailing address

PO BOX 1513
POPLAR MT
59255-1513
US

V. Phone/Fax

Practice location:
  • Phone: 406-786-3311
  • Fax:
Mailing address:
  • Phone: 605-216-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number74573
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number74573
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: