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General NPI Number Information
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NPI Number | 1013424225
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Entity Type | Organization
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Legal Business Name | MAKING A DIFFERENCE SUPPORT SERVICES, LLC
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Dates
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Enumeration Date | 01/09/2018
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Last Update Date | 04/04/2018
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Provider Practice Location Address
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Address Line | 1867 AIRPORT WAY STE 200
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City | FAIRBANKS
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State | AK
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Zip | 99701-4061
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Country | US
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Telephone | 907-750-7169
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Fax | 907-490-4469
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Provider Business Mailing Address
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Address Line | 1867 AIRPORT WAY STE 200
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City | FAIRBANKS
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State | AK
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Zip | 99701-4061
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Country | US
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Telephone | 907-750-7169
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Fax | 907-490-4469
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Authorized Official
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Title or Position | OWNER
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Name | CRYSTAL DEVON MCCORMICK
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Credential |
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Telephone | 907-750-7169
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSWS1053
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License Number State | AK
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