Healthcare Provider Details

I. General information

NPI: 1811866239
Provider Name (Legal Business Name): CRYSTA B GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4836 MAIN ST
MOSS POINT MS
39563-2700
US

IV. Provider business mailing address

PO BOX 2555
PASCAGOULA MS
39569-2555
US

V. Phone/Fax

Practice location:
  • Phone: 601-207-3928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC12225
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7015C
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: