MEDICARE: DR. KRYSTAL STUDIVANT NOWAK PSY.D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	0810005486	VA
2	103TC0700X	Clinical Psychologist	0810005486	VA

General Provider Information

NPI Number	:	1801215066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRYSTAL STUDIVANT NOWAK PSY.D.

Provider Business Mailing Address
First Line	:	1 PARK WEST CIR STE 306N
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-5552
Country	:	US
Telephone Number	:	804-719-1955
Fax Number	:	804-420-9680

Provider Business Practice Location Address
First Line	:	1 PARK WEST CIR STE 306N
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-5552
Country	:	US
Telephone Number	:	804-719-1955
Fax Number	:	804-420-9680

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

Provider Enumeration Date	:	04/15/2014
Last Update Date	:	09/14/2018

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