Healthcare Provider Details

I. General information

NPI: 1033731971
Provider Name (Legal Business Name): CRYSTAL WRAPE CASE MANAGER II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 W UNIVERSITY BLVD STE 100
DURANT OK
74701-2970
US

IV. Provider business mailing address

1976 COUNTY ROAD 4236
BONHAM TX
75418-9535
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7331
  • Fax: 580-924-7332
Mailing address:
  • Phone: 903-815-3958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: