Provider Demographics
NPI:1265751960
Name:HALTOM, KRYSTAL DAWN (MA, LPC)
Entity type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:DAWN
Last Name:HALTOM
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 S WESTERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-1816
Mailing Address - Country:US
Mailing Address - Phone:405-550-2688
Mailing Address - Fax:405-619-3924
Practice Address - Street 1:6801 S WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1816
Practice Address - Country:US
Practice Address - Phone:405-550-2688
Practice Address - Fax:405-619-3924
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200781380AMedicaid
OK1164939765OtherWORK NPI
OK82-0996935OtherDEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE
OK200375440BMedicaid