Provider Demographics
NPI:1073361549
Name:CRYSTAL MOON COUNSELING LLC
Entity type:Organization
Organization Name:CRYSTAL MOON COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:814-660-6257
Mailing Address - Street 1:413 S LOGAN BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-5643
Mailing Address - Country:US
Mailing Address - Phone:814-201-2750
Mailing Address - Fax:
Practice Address - Street 1:413 S LOGAN BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-5643
Practice Address - Country:US
Practice Address - Phone:814-201-2750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty