Provider Demographics
NPI:1568128841
Name:BREEDLOVE, CRYSTAL RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE
Last Name:BREEDLOVE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2872 BLAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-6134
Mailing Address - Country:US
Mailing Address - Phone:434-548-3011
Mailing Address - Fax:
Practice Address - Street 1:155 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2863
Practice Address - Country:US
Practice Address - Phone:434-835-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010980101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701010980Medicaid