Healthcare Provider Details

I. General information

NPI: 1265262612
Provider Name (Legal Business Name): CRYSTAL ROSE WISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL ROSE HASKINS

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S MAIN ST
LEBANON OR
97355-3109
US

IV. Provider business mailing address

PO BOX 100
ALBANY OR
97321-0031
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-5932
  • Fax: 541-812-8807
Mailing address:
  • Phone: 541-967-3866
  • Fax: 541-812-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC8013
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: