Basic Information
| Provider Information | |||||||||
| NPI: | 1538717418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Credential: | LMSW, CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 NAVARRE DR | ||||||||
| Address2: | |||||||||
| City: | STONE MOUNTAIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300875112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124414270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 175 GWINNETT DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782092394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | MSW008221 | GA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.