Provider Demographics
NPI:1265740054
Name:SUETHOLZ, CRYSTAL (LPCC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:SUETHOLZ
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:RUSK-TREMBLAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:688 BRANDTLY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-4228
Mailing Address - Country:US
Mailing Address - Phone:859-609-4454
Mailing Address - Fax:
Practice Address - Street 1:688 BRANDTLY RIDGE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41015-4228
Practice Address - Country:US
Practice Address - Phone:596-094-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174800101YP2500X
OHE.1000088101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional