Provider Demographics
NPI:1003486465
Name:KOUGIAS, KRYSTLE KRYSTALIA (LAC)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:KRYSTALIA
Last Name:KOUGIAS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 NEWTON AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLYN
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-1446
Mailing Address - Country:US
Mailing Address - Phone:609-543-9752
Mailing Address - Fax:
Practice Address - Street 1:304 NEWTON AVE
Practice Address - Street 2:
Practice Address - City:OAKLYN
Practice Address - State:NJ
Practice Address - Zip Code:08107-1446
Practice Address - Country:US
Practice Address - Phone:609-543-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health