Provider Demographics
NPI:1386220259
Name:LAUGAVITZ, CRYSTLE KAY (PMHNP)
Entity Type:Individual
Prefix:
First Name:CRYSTLE
Middle Name:KAY
Last Name:LAUGAVITZ
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-2141
Mailing Address - Country:US
Mailing Address - Phone:618-304-5388
Mailing Address - Fax:
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4713
Practice Address - Country:US
Practice Address - Phone:618-798-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023034363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health