=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073397162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL DAWN FONVILLE LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2023
-----------------------------------------------------
Last Update Date | 11/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1629 US HIGHWAY 190 E
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77351-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-259-2119
-----------------------------------------------------
Fax | 936-286-3106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1629 US HIGHWAY 190 E
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77351-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-259-2119
-----------------------------------------------------
Fax | 936-286-3106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 203893
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------