Provider Demographics
NPI:1669522116
Name:WAITES, CRYSTAL A (LPC, LCAS,LSC)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:A
Last Name:WAITES
Suffix:
Gender:F
Credentials:LPC, LCAS,LSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 KENMORE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-5792
Mailing Address - Country:US
Mailing Address - Phone:540-322-5424
Mailing Address - Fax:866-780-4133
Practice Address - Street 1:701 KENMORE AVE STE 105
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5792
Practice Address - Country:US
Practice Address - Phone:403-225-4245
Practice Address - Fax:866-780-4133
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1551101YA0400X
NC6638101YP2500X
NC3036101YS0200X
VA0701005844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103593Medicaid