Provider Demographics
NPI:1376772004
Name:WEISS, CRYSTAL ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:WEISS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840149
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-0149
Mailing Address - Country:US
Mailing Address - Phone:407-796-1832
Mailing Address - Fax:
Practice Address - Street 1:50 LEANNI WAY UNIT C4
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4755
Practice Address - Country:US
Practice Address - Phone:407-739-1832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW102741041C0700X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018981200Medicaid