Healthcare Provider Details

I. General information

NPI: 1023927266
Provider Name (Legal Business Name): CRYSTAL CLEAR MENTAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 KIMBERLY DR
CONVERSE TX
78109-1530
US

IV. Provider business mailing address

214 KIMBERLY DR
CONVERSE TX
78109-1530
US

V. Phone/Fax

Practice location:
  • Phone: 210-570-0214
  • Fax: 210-429-7851
Mailing address:
  • Phone: 210-570-0214
  • Fax: 210-429-7851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL WADE
Title or Position: OWNER/PROVIDER
Credential: PMHNP-BC
Phone: 941-447-4822