MEDICARE: MRS. KRYSTAL JEAN DEVAULT LCSW, LISW

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	104100000X	Social Worker	I.1801346	OH
2	1041C0700X	Clinical Social Worker	CW015706	PA

General Provider Information

NPI Number	:	1891728283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRYSTAL JEAN DEVAULT LCSW, LISW

Provider Business Mailing Address
First Line	:	202 LYTLE SCHOOL RD
Second Line	:
City	:	SANDY LAKE
State	:	PA
Zip	:	16145-3112
Country	:	US
Telephone Number	:	412-215-9417
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 LYTLE SCHOOL RD
Second Line	:
City	:	SANDY LAKE
State	:	PA
Zip	:	16145-3112
Country	:	US
Telephone Number	:	412-215-9417
Fax Number	:

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	07/14/2023

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