MEDICARE: CRYSTAL ROSE GOULART

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1588473953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL ROSE GOULART

Provider Business Mailing Address
First Line	:	5424 ASHBY ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-1824
Country	:	US
Telephone Number	:	707-327-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	5205 COLLEY AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2043
Country	:	US
Telephone Number	:	757-536-1233
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2024
Last Update Date	:	12/31/2024

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Directions to “ CRYSTAL ROSE GOULART ” Practice Location

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