Provider Demographics
NPI:1639623523
Name:FORTNEY, KRYSTAL DOMINIQUE (LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:DOMINIQUE
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 CABOT DR APT 115
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-4381
Mailing Address - Country:US
Mailing Address - Phone:901-827-7956
Mailing Address - Fax:
Practice Address - Street 1:4235 HILLSBORO PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-3344
Practice Address - Country:US
Practice Address - Phone:901-827-7956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC0000003700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional