Healthcare Provider Details

I. General information

NPI: 1164853438
Provider Name (Legal Business Name): CRYSTAL WALKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 ORCHID CIR
BELLPORT NY
11713-3010
US

IV. Provider business mailing address

1199 ORCHID CIR
BELLPORT NY
11713-3010
US

V. Phone/Fax

Practice location:
  • Phone: 631-334-0915
  • Fax:
Mailing address:
  • Phone: 631-334-0915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101595
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number094468
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: