Healthcare Provider Details

I. General information

NPI: 1376196386
Provider Name (Legal Business Name): CRYSTAL O'MEARA LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 KOKOMO DR
HUBBARD OH
44425-2841
US

IV. Provider business mailing address

1795 KOKOMO DR
HUBBARD OH
44425-2841
US

V. Phone/Fax

Practice location:
  • Phone: 330-397-1653
  • Fax:
Mailing address:
  • Phone: 330-397-1653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number163074
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: