1619202041 NPI number — CRYSTAL LYNN FAVRE LPC007028, GEORGIA

Table of content: CRYSTAL LYNN FAVRE LPC007028, GEORGIA (NPI 1619202041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619202041 NPI number — CRYSTAL LYNN FAVRE LPC007028, GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVRE
Provider First Name:
CRYSTAL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC007028, GEORGIA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619202041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 ROCKY RIDGE PASS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-9751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-786-2040
Provider Business Mailing Address Fax Number:
770-345-8801

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2404 REFUGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-4946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-692-7209
Provider Business Practice Location Address Fax Number:
706-693-0144
Provider Enumeration Date:
10/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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