Basic Information
| Provider Information | |||||||||
| NPI: | 1932535184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRYSTAL LAKE SUPPORTIVE ENVIRONMENTS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ATTAIN, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2710 STATEN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079653018 | ||||||||
| FaxNumber: | 8776902003 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 STATEN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328044211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079653018 | ||||||||
| FaxNumber: | 8776902003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4079653055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D., BCBA-D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 671009396 | 05 | FL | MEDICAID |