Provider Demographics
NPI:1184097230
Name:JOHNSON, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JOHNSON
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 1:39110 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-5038
Mailing Address - Country:US
Mailing Address - Phone:985-863-2591
Mailing Address - Fax:
Practice Address - Street 1:2053 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5449
Practice Address - Country:US
Practice Address - Phone:985-649-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009506945101Y00000X
LA6538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor