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General NPI Number Information
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NPI Number | 1013575877
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Entity Type | Individual
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Provider Name | CRYSTAL N. BROUGHTON
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Gender | Female
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Dates
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Enumeration Date | 06/05/2019
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Last Update Date | 01/31/2024
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Provider Practice Location Address
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Address Line | 1775 PARKER RD SE STE 210
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City | CONYERS
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State | GA
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Zip | 30094-6654
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Country | US
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Telephone | 470-967-8663
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Fax | 678-218-4253
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Provider Business Mailing Address
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Address Line | 1007 GREEN ST SE UNIT 1823
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City | CONYERS
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State | GA
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Zip | 30012-5556
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Country | US
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Telephone | 470-967-8663
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 013641
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License Number State | GA
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