Provider Demographics
NPI:1821427113
Name:GORE, KRYSTAL
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1003
Mailing Address - Country:US
Mailing Address - Phone:229-671-6100
Mailing Address - Fax:229-671-6774
Practice Address - Street 1:3120 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1003
Practice Address - Country:US
Practice Address - Phone:229-671-6100
Practice Address - Fax:229-671-6774
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3235106H00000X
GA001311106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA001311Other001311