MEDICARE: CRYSTAL COUNSELING PLLC

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	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1588923304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL COUNSELING PLLC

Provider Business Mailing Address
First Line	:	18756 STONE OAK PKWY
Second Line	:	SUITE 200
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4790
Country	:	US
Telephone Number	:	210-998-5591
Fax Number	:	210-579-1516

Provider Business Practice Location Address
First Line	:	116 GALLERY CIR STE 201
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3341
Country	:	US
Telephone Number	:	210-998-5591
Fax Number	:	210-579-1516

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LAWRENCE C MACK
Credential	:	LPC-S
Telephone Number	:	210-998-5591

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	01/22/2019

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