Healthcare Provider Details

I. General information

NPI: 1831601061
Provider Name (Legal Business Name): CRYSTAL L HARRIS MSSA, LSW,LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4269 PEARL RD
CLEVELAND OH
44109-4234
US

IV. Provider business mailing address

11906 SUMMERLAND AVE
CLEVELAND OH
44111-5059
US

V. Phone/Fax

Practice location:
  • Phone: 216-431-4131
  • Fax:
Mailing address:
  • Phone: 216-450-9526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS.1701473
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1701473
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number130671
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1701473
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: