MEDICARE: KRYSTAL DANELLE HERBERT LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P010815	NC

General Provider Information

NPI Number	:	1154871572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL DANELLE HERBERT LCSWA

Provider Business Mailing Address
First Line	:	800 CAROLINA ROSE TER
Second Line	:	APT 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-1582
Country	:	US
Telephone Number	:	336-317-1942
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 CAROLINA ROSE TER
Second Line	:	APT 202
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-1582
Country	:	US
Telephone Number	:	336-317-1942
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	10/10/2016

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