Healthcare Provider Details

I. General information

NPI: 1679958771
Provider Name (Legal Business Name): CRYSTAL MALLOY PHD, LPC, MAC, CEAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 SCHOLAR RD
GUYTON GA
31312-6240
US

IV. Provider business mailing address

174 SCHOLAR RD
GUYTON GA
31312-6240
US

V. Phone/Fax

Practice location:
  • Phone: 337-396-5592
  • Fax:
Mailing address:
  • Phone: 337-205-9357
  • Fax: 912-250-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6233
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberLPC8241
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLPC08241
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License NumberLC008241
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberLPC008241
License Number StateGA
# 7
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008241
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: