Healthcare Provider Details

I. General information

NPI: 1063033280
Provider Name (Legal Business Name): CRYSTAL EARLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL MCAVOY

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax:
Mailing address:
  • Phone: 541-440-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: