Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | GA |
NPI | 1003450040 |
---|---|
Provider Name | Crystal Monte Stephens |
First Address | Byron, GA 31008-9523 |
Second Address | Warner Robins, GA 31088-7640 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2019 |
Last Update Date | 02/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MAT | MAT (01) | GA |