Healthcare Provider Details

I. General information

NPI: 1063335925
Provider Name (Legal Business Name): CRYSTAL KENNERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 COBB PKWY NW STE 401
ACWORTH GA
30101-9528
US

IV. Provider business mailing address

2112 JOCKEY HOLLOW DR NW
KENNESAW GA
30152-3168
US

V. Phone/Fax

Practice location:
  • Phone: 470-645-0045
  • Fax:
Mailing address:
  • Phone: 470-645-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: