Organization
MAKING A DIFFERENCE SUPPORT SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CRYSTAL MCCORMICK LCSW (OWNER)
(907) 750-7169
Entity
Organization
Contact information
Practice address
1867 AIRPORT WAY, SUITE 200, FAIRBANKS, AK 99701-4054
(907) 750-7169
(907) 490-4469
Mailing address
1302 BENSHOOF DR, NORTH POLE, AK 99705-5666
(907) 590-2100
(907) 490-4469
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
1053
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1634221
—
AK
01
—
K164905
MEDICARE PTAN
AK
Enumeration date
04/18/2016
Last updated
04/18/2016
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