Provider Demographics
NPI:1619257953
Name:NICOSIA, CRYSTAL (LMHC)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:
Last Name:NICOSIA
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 1:165 SABAL PALM DRIVE. STE. 109
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779
Mailing Address - Country:US
Mailing Address - Phone:407-808-1900
Mailing Address - Fax:
Practice Address - Street 1:165 SABAL PALM DR STE 109
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2591
Practice Address - Country:US
Practice Address - Phone:407-808-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
FLMH 10789101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)