Healthcare Provider Details

I. General information

NPI: 1710457643
Provider Name (Legal Business Name): CRYSTAL D WITHERSPOON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E TRINITY PL
DECATUR GA
30030-3302
US

IV. Provider business mailing address

2085 BLACKHAWK TRL
LAWRENCEVILLE GA
30043-6479
US

V. Phone/Fax

Practice location:
  • Phone: 404-378-2300
  • Fax:
Mailing address:
  • Phone: 205-383-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW007818
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: