Healthcare Provider Details

I. General information

NPI: 1174376750
Provider Name (Legal Business Name): CRYSTAL KUYKENDALL LPC-MHSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 W MAIN ST
DECATURVILLE TN
38329-8033
US

IV. Provider business mailing address

10710 OLD HIGHWAY 64
BOLIVAR TN
38008-3587
US

V. Phone/Fax

Practice location:
  • Phone: 731-852-3112
  • Fax: 731-852-3222
Mailing address:
  • Phone: 731-658-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC6454
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6454
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: