Provider Demographics
NPI:1942571153
Name:JOHNSON, CRYSTAL DUANE (MS)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:DUANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S. BROADWAY AVE.
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-570-8513
Mailing Address - Fax:903-533-0673
Practice Address - Street 1:401 E FRONT STREET
Practice Address - Street 2:SUITE 139
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1608
Practice Address - Country:US
Practice Address - Phone:903-570-8513
Practice Address - Fax:903-533-0673
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9187101Y00000X
TX0831-0991101YA0400X
TX88106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist