Provider Demographics
NPI:1093323750
Name:BROWN, KRYSTAL J (LICSW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:J
Last Name:BROWN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:COTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:749 VAIL DR
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-9201
Mailing Address - Country:US
Mailing Address - Phone:802-745-7873
Mailing Address - Fax:
Practice Address - Street 1:215 STRATTON RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4621
Practice Address - Country:US
Practice Address - Phone:802-773-3386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01179241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical