Provider Demographics
NPI:1043551310
Name:WECKERT, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WECKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:HOULE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18562 MINOBIMAADIZI LOOP
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-3001
Mailing Address - Country:US
Mailing Address - Phone:320-532-4163
Mailing Address - Fax:320-532-2819
Practice Address - Street 1:18562 MINOBIMAADIZI LOOP
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-3001
Practice Address - Country:US
Practice Address - Phone:320-532-4163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2575106H00000X
MN175091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist