MEDICARE: CRYSTAL REANEE KISSELBURGH MA, LAC, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC.0026958	CO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	ACD.0001546	CO

General Provider Information

NPI Number	:	1669071213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL REANEE KISSELBURGH MA, LAC, LPCC

Provider Business Mailing Address
First Line	:	649 BROKEN SPOKE RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81504-6981
Country	:	US
Telephone Number	:	970-779-7824
Fax Number	:

Provider Business Practice Location Address
First Line	:	2956 NORTH AVE STE 1
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81504-3919
Country	:	US
Telephone Number	:	970-208-1103
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2020
Last Update Date	:	04/20/2022

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