Basic Information
| Provider Information | |||||||||
| NPI: | 1972989358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FICKEY | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ORONDO AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096643527 | ||||||||
| FaxNumber: | 5096644590 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 EASY WAY | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096624296 | ||||||||
| FaxNumber: | 5096641037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH60818946 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | LW60833199 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2084497 | 05 | WA | MEDICAID |