Provider Demographics
NPI:1497060404
Name:TREADWAY, CRYSTAL NICKY (LMHC,NCC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:NICKY
Last Name:TREADWAY
Suffix:
Gender:F
Credentials:LMHC,NCC
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC, NCC
Mailing Address - Street 1:1952 SW JAMESPORT DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4377
Mailing Address - Country:US
Mailing Address - Phone:561-315-4841
Mailing Address - Fax:
Practice Address - Street 1:201 SW PORT ST LUCIE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5001
Practice Address - Country:US
Practice Address - Phone:561-315-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 12436101YM0800X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)