Provider Demographics
NPI:1003635376
Name:LEDDY, KRYSTAL LIGHT (PSYD)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:LIGHT
Last Name:LEDDY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 S TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-5046
Mailing Address - Country:US
Mailing Address - Phone:316-744-5354
Mailing Address - Fax:
Practice Address - Street 1:249 CENTRAL PARK AVE STE 300
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3271
Practice Address - Country:US
Practice Address - Phone:757-231-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical