Provider Demographics
NPI:1427238070
Name:HARSTAD, CRYSTAL D (MS, LPA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:D
Last Name:HARSTAD
Suffix:
Gender:F
Credentials:MS, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1275
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 NEWTOWN PIKE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY137644103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid
KY30615058Medicaid