Healthcare Provider Details

I. General information

NPI: 1841648540
Provider Name (Legal Business Name): KRYSTAL DELEON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRYSTAL JUDAH

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605C FOXGLOVE LN APT 12
WHITEWATER WI
53190-2669
US

IV. Provider business mailing address

605C FOXGLOVE LN APT 12
WHITEWATER WI
53190-2669
US

V. Phone/Fax

Practice location:
  • Phone: 608-473-2093
  • Fax:
Mailing address:
  • Phone: 608-473-2093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10729-125
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10729-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: