Provider Demographics
NPI:1770981383
Name:WASDEN, CHRYSTAL
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:
Last Name:WASDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRYSTAL
Other - Middle Name:ANN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2009 HIWASSEE DR
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-2509
Mailing Address - Country:US
Mailing Address - Phone:478-953-5618
Mailing Address - Fax:
Practice Address - Street 1:2009 HIWASSEE DR
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-2509
Practice Address - Country:US
Practice Address - Phone:478-953-5618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007231101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor