Provider Demographics
NPI:1750687992
Name:WORTHINGTON, KRYSTALROSE (LCPC)
Entity Type:Individual
Prefix:
First Name:KRYSTALROSE
Middle Name:
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:TURNER-SCHOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, LPC
Mailing Address - Street 1:2705 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6601
Mailing Address - Country:US
Mailing Address - Phone:208-821-8688
Mailing Address - Fax:
Practice Address - Street 1:2705 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-06
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-7195101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health