Basic Information
| Provider Information | |||||||||
| NPI: | 1669522116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITES | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LPC, LCAS,LSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 KENMORE AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224015792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403225424 | ||||||||
| FaxNumber: | 8667804133 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 KENMORE AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224015792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4032254245 | ||||||||
| FaxNumber: | 8667804133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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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 | 101YA0400X | 1551 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 6638 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YS0200X | 3036 | NC | N | Behavioral Health & Social Service Providers | Counselor | School | 101YP2500X | 0701005844 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6103593 | 05 | NC | MEDICAID |