Provider Demographics
NPI:1093192338
Name:HART, CRYSTAL L (LAC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:THRASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHPP
Mailing Address - Street 1:1600 ALDERSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:501-325-7938
Practice Address - Street 1:1112 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173
Practice Address - Country:US
Practice Address - Phone:501-772-9278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1805053101YM0800X
171M00000X
AR171M00000X
ARP2012114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator