MEDICARE: CRYSTAL DAWN FONVILLE LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	203893	TX

General Provider Information

NPI Number	:	1073397162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DAWN FONVILLE LMFT

Provider Business Mailing Address
First Line	:	1629 US HIGHWAY 190 E
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-4487
Country	:	US
Telephone Number	:	936-259-2119
Fax Number	:	936-286-3106

Provider Business Practice Location Address
First Line	:	1629 US HIGHWAY 190 E
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-4487
Country	:	US
Telephone Number	:	936-259-2119
Fax Number	:	936-286-3106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2023
Last Update Date	:	11/11/2025

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