Provider Demographics
NPI:1043682420
Name:JOHNSON, CRYSTAL (LPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 POINT VIEW CT
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2094
Mailing Address - Country:US
Mailing Address - Phone:678-296-5458
Mailing Address - Fax:
Practice Address - Street 1:1303 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3566
Practice Address - Country:US
Practice Address - Phone:770-862-6088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional