Provider Demographics
NPI:1285381335
Name:MERCADO, CRYSTAL G
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:G
Last Name:MERCADO
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 1:9433 SW 51ST CT
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-4105
Mailing Address - Country:US
Mailing Address - Phone:954-982-4776
Mailing Address - Fax:
Practice Address - Street 1:1000 NW 65TH ST STE 201
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1113
Practice Address - Country:US
Practice Address - Phone:954-271-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-186930106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician