Healthcare Provider Details

I. General information

NPI: 1235442013
Provider Name (Legal Business Name): CRYSTAL R MAYFIELD BSW, CADC, CSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 CINCINNATI RD
GEORGETOWN KY
40324-9505
US

IV. Provider business mailing address

3107 CINCINNATI RD
GEORGETOWN KY
40324-9505
US

V. Phone/Fax

Practice location:
  • Phone: 502-570-9313
  • Fax:
Mailing address:
  • Phone: 502-570-9313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0898
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: