Provider Demographics
NPI:1396131199
Name:LUMPKIN, KRYSTAL LYLE
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYLE
Last Name:LUMPKIN
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 1:1414 WINDMOOR CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1269
Mailing Address - Country:US
Mailing Address - Phone:404-809-7374
Mailing Address - Fax:
Practice Address - Street 1:9876 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3990
Practice Address - Country:US
Practice Address - Phone:770-516-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional