Provider Demographics
NPI:1003450040
Name:STEPHENS, CRYSTAL MONTE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MONTE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 COVINGTON CV
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-9523
Mailing Address - Country:US
Mailing Address - Phone:478-832-8735
Mailing Address - Fax:
Practice Address - Street 1:607 RUSSELL PKWY
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7640
Practice Address - Country:US
Practice Address - Phone:478-225-9860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMATOtherMAT