Healthcare Provider Details

I. General information

NPI: 1790554566
Provider Name (Legal Business Name): CRYSTAL WHITE LCSW-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TARPON TRL
JACKSONVILLE NC
28546-5287
US

IV. Provider business mailing address

9429 HWY 41 W
PINK HILL NC
28572-7021
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-1114
  • Fax: 910-938-1118
Mailing address:
  • Phone: 910-650-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: