Provider Demographics
NPI:1851056196
Name:PORTEE-HARMAN, CRYSTAL Y
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:Y
Last Name:PORTEE-HARMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DOCTORS DR STE J
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6308
Mailing Address - Country:US
Mailing Address - Phone:910-333-0814
Mailing Address - Fax:
Practice Address - Street 1:200 DOCTORS DR STE J
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6308
Practice Address - Country:US
Practice Address - Phone:910-333-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC29478101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid