Healthcare Provider Details

I. General information

NPI: 1457275703
Provider Name (Legal Business Name): CRYSTAL BENNETT GREEN MA, LPC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2026
Last Update Date: 08/08/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WESMARK CT
SUMTER SC
29150-1996
US

IV. Provider business mailing address

41 SUMTER CT
MANNING SC
29102-3256
US

V. Phone/Fax

Practice location:
  • Phone: 803-883-4981
  • Fax: 803-883-5492
Mailing address:
  • Phone: 803-410-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11095
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: