Basic Information
| Provider Information | |||||||||
| NPI: | 1679723241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DILLARD | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | L | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 DRAWER 1492 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352461492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399193 | ||||||||
| FaxNumber: | 2059399949 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 7TH AVE S | ||||||||
| Address2: | ACC 500 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399193 | ||||||||
| FaxNumber: | 2059399949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 03/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1545 | AL | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 1545 | AL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TH0100X | 2829 | TN | N | Behavioral Health & Social Service Providers | Psychologist | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 515-97317 | 01 | AL | BCBS | OTHER | 515-98119 | 01 | AL | FEDERAL BC | OTHER | 1679723241 | 01 | AL | TRICARE SOUTH | OTHER | 515-97316 | 01 | AL | BCBS | OTHER | 515-98120 | 01 | AL | FEDERAL BC | OTHER | 109018 | 05 | AL | MEDICAID | 109021 | 05 | AL | MEDICAID |