Provider Demographics
NPI:1578943197
Name:RUCKER-RASPBERRY, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:RUCKER-RASPBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2701 HARLECK CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CENTERVIEW DR STE 110
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3709
Practice Address - Country:US
Practice Address - Phone:336-887-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11521101YP2500X, 101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health