Provider Demographics
NPI:1063687036
Name:CORBIN, CRYSTAL LEA (LPC #3452)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEA
Last Name:CORBIN
Suffix:
Gender:F
Credentials:LPC #3452
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1496
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-1496
Mailing Address - Country:US
Mailing Address - Phone:318-747-4070
Mailing Address - Fax:318-742-4162
Practice Address - Street 1:2285 BENTON RD
Practice Address - Street 2:SUITE D-201, OFFICE 1
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7933
Practice Address - Country:US
Practice Address - Phone:318-747-4070
Practice Address - Fax:318-742-4162
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA#3452101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor