Provider Demographics
NPI:1679958771
Name:MALLOY, CRYSTAL (PHD, LPC, MAC, CEAP)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PHD, LPC, MAC, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 SCHOLAR RD
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-6240
Mailing Address - Country:US
Mailing Address - Phone:337-205-9357
Mailing Address - Fax:912-250-6025
Practice Address - Street 1:174 SCHOLAR RD
Practice Address - Street 2:
Practice Address - City:GUYTON
Practice Address - State:GA
Practice Address - Zip Code:31312-6240
Practice Address - Country:US
Practice Address - Phone:337-396-5592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
LA6233101YP2500X
GALPC08241106H00000X
GALPC8241221700000X
GALPC0082412080P0006X, 101YP2500X
GALC008241225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid