Provider Demographics
NPI:1598344640
Name:KINMON, CRYSTAL MARIE (LCDC-I)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:KINMON
Suffix:
Gender:F
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 MCCART AVE STE H
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-3700
Mailing Address - Country:US
Mailing Address - Phone:817-207-8700
Mailing Address - Fax:
Practice Address - Street 1:5201 MCCART AVE STE H
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-3700
Practice Address - Country:US
Practice Address - Phone:817-207-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)