Healthcare Provider Details

I. General information

NPI: 1760136568
Provider Name (Legal Business Name): CHRYSTAL JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3527 N ROLLING RD STE 7
WINDSOR MILL MD
21244-2256
US

IV. Provider business mailing address

4234 HUNTSHIRE RD
RANDALLSTOWN MD
21133-4067
US

V. Phone/Fax

Practice location:
  • Phone: 443-272-7158
  • Fax:
Mailing address:
  • Phone: 443-272-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number211211926
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number211211929
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number211211926
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number10148
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number211211928
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: