Provider Demographics
NPI:1265675375
Name:KRYSTAL'S HOUSE, LLC
Entity Type:Organization
Organization Name:KRYSTAL'S HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:HODGES
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-747-2988
Mailing Address - Street 1:208 N GREENE ST
Mailing Address - Street 2:
Mailing Address - City:SNOW HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28580-1410
Mailing Address - Country:US
Mailing Address - Phone:252-747-2988
Mailing Address - Fax:252-747-4330
Practice Address - Street 1:208 N GREENE ST
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-1410
Practice Address - Country:US
Practice Address - Phone:252-747-2988
Practice Address - Fax:252-747-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty