Provider Demographics
NPI:1134950637
Name:MCINNIS, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MCINNIS
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 1:826 NIGHTHAWK PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5653
Mailing Address - Country:US
Mailing Address - Phone:910-280-5304
Mailing Address - Fax:
Practice Address - Street 1:6885 CLIFFDALE RD STE 202
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2834
Practice Address - Country:US
Practice Address - Phone:910-339-0400
Practice Address - Fax:910-339-0396
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20259101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional