Basic Information
| Provider Information | |||||||||
| NPI: | 1720758626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95-014 WAIHONU ST APT E304 | ||||||||
| Address2: | |||||||||
| City: | MILILANI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967893302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096373960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 103 BODIN CIRCLE | ||||||||
| Address2: | TRAVIS AFB | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-18793 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.