Healthcare Provider Details

I. General information

NPI: 1306766134
Provider Name (Legal Business Name): NICOLE CRISAN RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 WHITE RABBIT RUN
ST AUGUSTINE FL
32092-0191
US

IV. Provider business mailing address

70 WHITE RABBIT RUN
ST AUGUSTINE FL
32092-0191
US

V. Phone/Fax

Practice location:
  • Phone: 480-877-9284
  • Fax:
Mailing address:
  • Phone: 480-877-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: