Provider Demographics
NPI:1295189702
Name:PELLOM, CRYSTAL KOREN (LPC-A)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:KOREN
Last Name:PELLOM
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-343-0145
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412
Practice Address - Country:US
Practice Address - Phone:910-343-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12297101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health