=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184360521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL CLEAR HEALING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2022
-----------------------------------------------------
Last Update Date | 05/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 842 S WOLCOTT DR
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-334-6333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 842 S WOLCOTT DR
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-334-6333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ABIGAIL BENSKO
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 719-334-6333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------