Provider Demographics
NPI:1609354851
Name:MCCRYSTAL, KATHRYN HANKS (TCADC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:HANKS
Last Name:MCCRYSTAL
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:HANKS
Other - Last Name:MCCRYSTAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:TCADC
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1134
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY281893101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid