Provider Demographics
NPI:1609467620
Name:RAULLERSON, CRYSTAL (LMHC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:RAULLERSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6747 GIANT OAK LN APT 195
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-3546
Mailing Address - Country:US
Mailing Address - Phone:407-639-2557
Mailing Address - Fax:
Practice Address - Street 1:7000 W PALMETTO PARK RD STE 407
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3425
Practice Address - Country:US
Practice Address - Phone:954-227-2700
Practice Address - Fax:954-227-2704
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health