Provider Demographics
NPI:1740004670
Name:WILKERSON, CRYSTAL RAE
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:RAE
Last Name:WILKERSON
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 1:14 PINEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-9169
Mailing Address - Country:US
Mailing Address - Phone:803-878-9217
Mailing Address - Fax:
Practice Address - Street 1:2144 SUMTER ST STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2182
Practice Address - Country:US
Practice Address - Phone:803-258-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-24-347719106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty