=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609949742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL VENICE MCLEOD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 04/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49TH MEDICAL GROUP/SGOPF 280 FIRST STREET, BLDG 23
-----------------------------------------------------
City | HOLLOMAN AFB
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88330-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-572-7091
-----------------------------------------------------
Fax | 575-572-2259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49TH MEDICAL GROUP/SGOW 280 FIRST STREET, BLDG 23
-----------------------------------------------------
City | HOLLOMAN AFB
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88330-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-572-7091
-----------------------------------------------------
Fax | 575-572-2259
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P003475
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------