Provider Demographics
NPI:1265933816
Name:MYCROFT, KRISTY L (LPC)
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:L
Last Name:MYCROFT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 GLENDA CT
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7368
Mailing Address - Country:US
Mailing Address - Phone:404-877-2190
Mailing Address - Fax:
Practice Address - Street 1:5960 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2372
Practice Address - Country:US
Practice Address - Phone:404-877-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009749101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional