Provider Demographics
NPI:1609336619
Name:EVANS, CRYSTAL (LAC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 LITTLE RIVER 11
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-8985
Mailing Address - Country:US
Mailing Address - Phone:903-276-1399
Mailing Address - Fax:
Practice Address - Street 1:508 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3925
Practice Address - Country:US
Practice Address - Phone:870-455-0134
Practice Address - Fax:870-277-2230
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1903040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health