Provider Demographics
NPI:1639601461
Name:KRYSTAL NOWAK PSYCHOLOGY LLC
Entity Type:Organization
Organization Name:KRYSTAL NOWAK PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:STUDIVANT
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:804-719-1955
Mailing Address - Street 1:4920 MILLRIDGE PKWY E
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4920 MILLRIDGE PKWY E
Practice Address - Street 2:SUITE 206
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4857
Practice Address - Country:US
Practice Address - Phone:804-719-1955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005486103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty