Provider Demographics
NPI:1710457643
Name:WITHERSPOON, CRYSTAL D (LMSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:WITHERSPOON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 BLACKHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6479
Mailing Address - Country:US
Mailing Address - Phone:205-383-7011
Mailing Address - Fax:
Practice Address - Street 1:120 E TRINITY PL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3302
Practice Address - Country:US
Practice Address - Phone:404-378-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0078181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical