Provider Demographics
NPI:1588473953
Name:GOULART, CRYSTAL ROSE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:GOULART
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 1:5424 ASHBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1824
Mailing Address - Country:US
Mailing Address - Phone:707-327-6006
Mailing Address - Fax:
Practice Address - Street 1:5205 COLLEY AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2043
Practice Address - Country:US
Practice Address - Phone:757-536-1233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional