Provider Demographics
NPI:1740933795
Name:SMITH, KRYSTAL R (MS, LPC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4455
Practice Address - Country:US
Practice Address - Phone:715-832-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5282-226101YP2500X
WI10990-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional