Provider Demographics
NPI:1841648540
Name:DELEON, KRYSTAL (LPC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:DELEON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:JUDAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605C FOXGLOVE LN APT 12
Mailing Address - Street 2:
Mailing Address - City:WHITEWATER
Mailing Address - State:WI
Mailing Address - Zip Code:53190-2669
Mailing Address - Country:US
Mailing Address - Phone:608-473-2093
Mailing Address - Fax:
Practice Address - Street 1:605C FOXGLOVE LN APT 12
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-2669
Practice Address - Country:US
Practice Address - Phone:608-473-2093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10729-125101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1841648540Medicaid