Provider Demographics
NPI:1104700731
Name:LAWRENCE, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12203 BRAXFIELD CT APT 1
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2010
Mailing Address - Country:US
Mailing Address - Phone:404-992-9172
Mailing Address - Fax:
Practice Address - Street 1:15 W GUDE DR STE 400
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-1168
Practice Address - Country:US
Practice Address - Phone:240-740-9931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13331103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool