Provider Demographics
NPI:1942778485
Name:SMITH, CHRYSTALA
Entity Type:Individual
Prefix:
First Name:CHRYSTALA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRYSTALA
Other - Middle Name:
Other - Last Name:LIVINGSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:118 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2832
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-946-0991
Practice Address - Street 1:101 ADAMS ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-3058
Practice Address - Country:US
Practice Address - Phone:573-556-6589
Practice Address - Fax:573-556-6294
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017042232101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional