=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023927266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL CLEAR MENTAL WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2026
-----------------------------------------------------
Last Update Date | 09/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 KIMBERLY DR
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-570-0214
-----------------------------------------------------
Fax | 210-429-7851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 KIMBERLY DR
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-570-0214
-----------------------------------------------------
Fax | 210-429-7851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | CRYSTAL WADE
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 941-447-4822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------