Provider Demographics
NPI:1013575877
Name:BROUGHTON, CRYSTAL N
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:N
Last Name:BROUGHTON
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 1:1007 GREEN ST SE UNIT 1823
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-5556
Mailing Address - Country:US
Mailing Address - Phone:470-967-8663
Mailing Address - Fax:
Practice Address - Street 1:1775 PARKER RD SE STE 210
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6654
Practice Address - Country:US
Practice Address - Phone:470-967-8663
Practice Address - Fax:678-218-4253
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
GA013641101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor