Provider Demographics
NPI:1023668191
Name:SMALL, CRYSTAL NICOLE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:SMALL
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 1:7901 4TH ST N STE 4000
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4305
Mailing Address - Country:US
Mailing Address - Phone:352-672-8663
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-672-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty