MEDICARE: CRYSTAL ANN WEISS LCSW

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	1041C0700X	Clinical Social Worker	SW10274	FL

General Provider Information

NPI Number	:	1376772004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL ANN WEISS LCSW

Provider Business Mailing Address
First Line	:	PO BOX 840149
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32080-0149
Country	:	US
Telephone Number	:	407-796-1832
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 LEANNI WAY UNIT C4
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-4755
Country	:	US
Telephone Number	:	407-739-1832
Fax Number	:

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

Provider Enumeration Date	:	07/01/2009
Last Update Date	:	11/04/2023

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