Provider Demographics
NPI:1417193244
Name:WHITE, CHRYSTAL DAWN (MED, LAC)
Entity Type:Individual
Prefix:MS
First Name:CHRYSTAL
Middle Name:DAWN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 A ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-3653
Mailing Address - Country:US
Mailing Address - Phone:870-234-2600
Mailing Address - Fax:870-234-2606
Practice Address - Street 1:229 A ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3653
Practice Address - Country:US
Practice Address - Phone:870-234-2600
Practice Address - Fax:870-234-2606
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0302012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health