Provider Demographics
NPI:1629360987
Name:COLE, CRYSTAL SHAVAUN
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:SHAVAUN
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BOGEY LN APT 2
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-8947
Mailing Address - Country:US
Mailing Address - Phone:501-993-6448
Mailing Address - Fax:
Practice Address - Street 1:6425 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1509
Practice Address - Country:US
Practice Address - Phone:501-666-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health