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General NPI Number Information
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NPI Number | 1114366531
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Entity Type | Organization
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Legal Business Name | CRYSTAL CLEAR BEHAVIORAL HEALTH SERVICES
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Dates
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Enumeration Date | 06/19/2013
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Last Update Date | 11/11/2022
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Provider Practice Location Address
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Address Line | 1818 RIDGE ROAD UNIT 104
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City | HOMEWOOD
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State | IL
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Zip | 60430-1763
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Country | US
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Telephone | 708-275-0937
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Fax | 815-521-1889
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Provider Business Mailing Address
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Address Line | 4304A E CENTRAL TEXAS EXPY STE A
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City | KILLEEN
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State | TX
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Zip | 76543-7308
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Country | US
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Telephone | 708-275-0937
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Fax | 708-310-6057
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Authorized Official
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Title or Position | OWNER
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Name | TAMARA FIELDS
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Credential | LCSW
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Telephone | 708-275-0937
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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 | 149.014385
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License Number State | IL
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