Healthcare Provider Details

I. General information

NPI: 1982088605
Provider Name (Legal Business Name): CRYSTAL ELLISON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

IV. Provider business mailing address

218 BROADWAY BLVD SE
ALBUQUERQUE NM
87102-3425
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-6988
  • Fax: 505-242-6972
Mailing address:
  • Phone: 505-242-6988
  • Fax: 505-242-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10657
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: