Provider Demographics
NPI:1093321192
Name:STATEN, KRISTY LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:LYNN
Last Name:STATEN
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 1:2575 TANK RD
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-8394
Mailing Address - Country:US
Mailing Address - Phone:601-951-4341
Mailing Address - Fax:
Practice Address - Street 1:506 W MARION AVE STE A
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2720
Practice Address - Country:US
Practice Address - Phone:601-497-8242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC89561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical