Basic Information
| Provider Information | |||||||||
| NPI: | 1336547009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | SHIRELLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861565 | ||||||||
| FaxNumber: | 7049861565 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 PEE DEE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2014 | ||||||||
| LastUpdateDate: | 09/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A14791 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.