Healthcare Provider Details

I. General information

NPI: 1629282124
Provider Name (Legal Business Name): CRYSTAL TACK ND LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 HOUSE RD
SEQUIM WA
98382-6809
US

IV. Provider business mailing address

344 HOUSE RD
SEQUIM WA
98382-6809
US

V. Phone/Fax

Practice location:
  • Phone: 360-683-2937
  • Fax:
Mailing address:
  • Phone: 360-683-2937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT00000627
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00000023
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: