Provider Demographics
NPI:1447270509
Name:ROBERTS, CRYSTAL L (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 JORDAN ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4526
Mailing Address - Country:US
Mailing Address - Phone:318-200-0504
Mailing Address - Fax:
Practice Address - Street 1:820 JORDAN ST STE 550
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4526
Practice Address - Country:US
Practice Address - Phone:318-200-0504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
7937101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018213Medicaid