Healthcare Provider Details

I. General information

NPI: 1609467620
Provider Name (Legal Business Name): CRYSTAL RAULLERSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 W PALMETTO PARK RD STE 407
BOCA RATON FL
33433-3425
US

IV. Provider business mailing address

6747 GIANT OAK LN APT 195
ORLANDO FL
32810-3546
US

V. Phone/Fax

Practice location:
  • Phone: 954-227-2700
  • Fax: 954-227-2704
Mailing address:
  • Phone: 407-639-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18749
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: