Healthcare Provider Details

I. General information

NPI: 1356897656
Provider Name (Legal Business Name): KRYSTAL ANDERSON LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110-B BRANCHWOOD DRIVE
JACKSONVILLE NC
28546
US

IV. Provider business mailing address

800 TALON CIR APT. 1E
JACKSONVILLE NC
28546-7167
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-9833
  • Fax:
Mailing address:
  • Phone: 910-938-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP009218
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: