Provider Demographics
NPI:1932677283
Name:RAU, KRYSTAL (LPC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:RAU
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 TRADE CENTRE WAY STE 140
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-0411
Mailing Address - Country:US
Mailing Address - Phone:517-882-3732
Mailing Address - Fax:517-882-3633
Practice Address - Street 1:650 TRADE CENTRE WAY STE 140
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-0411
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:517-882-3633
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016935101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional