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General NPI Number Information
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NPI Number | 1801300702
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Entity Type | Individual
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Provider Name | CRYSTAL MARIE WAVRICK
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Gender | Female
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Dates
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Enumeration Date | 11/30/2017
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Last Update Date | 11/30/2017
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Provider Practice Location Address
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Address Line | 619 SW HIGGINS AVE STE E
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City | MISSOULA
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State | MT
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Zip | 59803-1430
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Country | US
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Telephone | 406-728-9672
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Fax |
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Provider Business Mailing Address
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Address Line | 4998 SONOMA ST
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City | MISSOULA
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State | MT
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Zip | 59808-8694
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Country | US
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Telephone | 406-544-3551
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | BBH-LCSW-LIC-25772
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License Number State | MT
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