Provider Demographics
NPI:1083156582
Name:BRUNSON, CRYSTAL NIKIA (LCMHCA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NIKIA
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:NIKIA
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8376 SIX FORKS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5095
Mailing Address - Country:US
Mailing Address - Phone:919-900-7438
Mailing Address - Fax:
Practice Address - Street 1:8376 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5095
Practice Address - Country:US
Practice Address - Phone:919-900-7438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1167989101YS0200X
NCA10494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool