Healthcare Provider Details

I. General information

NPI: 1023767993
Provider Name (Legal Business Name): CRYSTAL DEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

324 STOKES CREEK DR
SAINT AUGUSTINE FL
32095-6809
US

IV. Provider business mailing address

324 STOKES CREEK DR
SAINT AUGUSTINE FL
32095-6809
US

V. Phone/Fax

Practice location:
  • Phone: 276-790-8673
  • Fax:
Mailing address:
  • Phone: 276-790-8673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: