Healthcare Provider Details

I. General information

NPI: 1689408031
Provider Name (Legal Business Name): CREYSTAL DEMI FAGBOHUN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3126 RICH RD
MARIETTA GA
30066-3802
US

IV. Provider business mailing address

3126 RICH RD
MARIETTA GA
30066-3802
US

V. Phone/Fax

Practice location:
  • Phone: 770-903-2150
  • Fax:
Mailing address:
  • Phone: 770-903-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW007521
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: