Healthcare Provider Details

I. General information

NPI: 1003565946
Provider Name (Legal Business Name): CRYSTAL BANKS M.S. RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2022
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3544 EDGEWATER DR
ORLANDO FL
32804-2922
US

IV. Provider business mailing address

15055 LAKE BRITT CIR APT 1201
WINTER GARDEN FL
34787-7107
US

V. Phone/Fax

Practice location:
  • Phone: 407-291-8009
  • Fax: 407-770-5503
Mailing address:
  • Phone: 253-468-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH24101
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: