Healthcare Provider Details

I. General information

NPI: 1609453489
Provider Name (Legal Business Name): KRYSTAL DIANNE HINES NCC, LCMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date: 05/10/2026
Reactivation Date: 06/09/2026

III. Provider practice location address

3705 LATROBE DRIVE SUITE 340
CHARLOTTE NC
28211
US

IV. Provider business mailing address

3705 LATROBE DRIVE SUITE 340
CHARLOTTE NC
28211
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-3989
  • Fax:
Mailing address:
  • Phone: 704-364-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: