Provider Demographics
NPI:1043725781
Name:ANTLE, CRYSTAL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:ANTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12636 LARIAT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-3035
Mailing Address - Country:US
Mailing Address - Phone:225-978-8336
Mailing Address - Fax:225-367-4927
Practice Address - Street 1:7620 GOODWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7622
Practice Address - Country:US
Practice Address - Phone:225-978-0008
Practice Address - Fax:225-367-4927
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA83311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical