Provider Demographics
NPI:1629480918
Name:LEWIS, KRYSTAL (LPC, LCDC, MAC, SAP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPC, LCDC, MAC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PEWTER CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-5906
Mailing Address - Country:US
Mailing Address - Phone:931-255-2418
Mailing Address - Fax:
Practice Address - Street 1:1001 PEWTER CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-5906
Practice Address - Country:US
Practice Address - Phone:931-255-2418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78459101Y00000X, 101YM0800X, 101YP2500X
TX12503101YA0400X
TN6314101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health