=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093321192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTY LYNN STATEN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 09/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 W MARION AVE STE A
-----------------------------------------------------
City | CRYSTAL SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39059-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-497-8242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2575 TANK RD
-----------------------------------------------------
City | TERRY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39170-8394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-951-4341
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C8956
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------