Provider Demographics
NPI:1659985190
Name:WHITESELL, CRYSTAL (MA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21261 IVY RD
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-8219
Mailing Address - Country:US
Mailing Address - Phone:417-673-5633
Mailing Address - Fax:
Practice Address - Street 1:21261 IVY RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-8219
Practice Address - Country:US
Practice Address - Phone:417-673-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175958101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional