Provider Demographics
NPI:1124673157
Name:MIYAMOTO, KRYSTYL WYNE (LMHC, LICSWA)
Entity type:Individual
Prefix:
First Name:KRYSTYL
Middle Name:WYNE
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:LMHC, LICSWA
Other - Prefix:
Other - First Name:KRYSTYL
Other - Middle Name:WYNE
Other - Last Name:NETTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14 N GRADY LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99016-8610
Mailing Address - Country:US
Mailing Address - Phone:509-609-6731
Mailing Address - Fax:
Practice Address - Street 1:14 N GRADY LN
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99016-8610
Practice Address - Country:US
Practice Address - Phone:509-609-6731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60978657104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker