Basic Information
| Provider Information | |||||||||
| NPI: | 1447328190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIST | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1316 SOMERVILLE RD SE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356014305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4110 US HIGHWAY 31 S | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356031644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563556105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC 2023 | AL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 051502828 | 01 | AL | BCBS OF AL PROVIDER # | OTHER |