Provider Demographics
NPI:1316635857
Name:WHITECOTTON, CRYSTAL MARIE (LICDC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:WHITECOTTON
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-4358
Mailing Address - Country:US
Mailing Address - Phone:304-639-2694
Mailing Address - Fax:
Practice Address - Street 1:3810 WOOD ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-4358
Practice Address - Country:US
Practice Address - Phone:304-639-2694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.16323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)