Provider Demographics
NPI:1760130603
Name:COATES, KRYSTLE LYNN
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:LYNN
Last Name:COATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTLE
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:911 N GOLIAD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-2230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4557
Practice Address - Country:US
Practice Address - Phone:469-458-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-206042106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician