MEDICARE: KRYSTLE DANDRIDGE LPC

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	101YP2500X	Professional Counselor	0701005810	VA

General Provider Information

NPI Number	:	1578974283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTLE DANDRIDGE LPC

Provider Business Mailing Address
First Line	:	5511 STAPLES MILL RD STE 102
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5445
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5511 STAPLES MILL RD STE 102
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-5445
Country	:	US
Telephone Number	:	609-314-3099
Fax Number	:

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

Provider Enumeration Date	:	05/15/2014
Last Update Date	:	05/15/2014

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