Provider Demographics
NPI:1770919029
Name:KITTRELL-JOHNSON, CRYSTAL (PHD, LPC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KITTRELL-JOHNSON
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 BRIDGE RD STE 8
Mailing Address - Street 2:#201
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435
Mailing Address - Country:US
Mailing Address - Phone:757-632-7107
Mailing Address - Fax:
Practice Address - Street 1:3575 BRIDGE RD STE 8
Practice Address - Street 2:# 201
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435
Practice Address - Country:US
Practice Address - Phone:757-632-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004619101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701004619OtherLICENSED PROFESSIONAL COUNSELOR