MEDICARE: CRYSTAL D COLINA MSW, LCSW, MCAPI

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker	SW15127	FL

General Provider Information

NPI Number	:	1437683984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL D COLINA MSW, LCSW, MCAPI

Provider Business Mailing Address
First Line	:	1026 SW SULTAN DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2645
Country	:	US
Telephone Number	:	864-275-8398
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 SE MARTIN SQUARE CORPORATE PKWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-4916
Country	:	US
Telephone Number	:	772-444-7911
Fax Number	:

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

Provider Enumeration Date	:	04/11/2017
Last Update Date	:	05/01/2018

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