MEDICARE: CRYSTAL LOUISE PERDUE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2019006727	MO
2	101YM0800X	Mental Health Counselor	MH20972	FL

General Provider Information

NPI Number	:	1154055747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LOUISE PERDUE LPC

Provider Business Mailing Address
First Line	:	PO BOX 25331
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33102-5331
Country	:	US
Telephone Number	:	913-432-7722
Fax Number	:

Provider Business Practice Location Address
First Line	:	1317 MANDARIN ISLE
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-1648
Country	:	US
Telephone Number	:	913-432-7722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	07/11/2022

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