Provider Demographics
NPI:1972196608
Name:MANSO, KRYSTYNA ISEL (MSPSY, LMHC)
Entity type:Individual
Prefix:
First Name:KRYSTYNA
Middle Name:ISEL
Last Name:MANSO
Suffix:
Gender:F
Credentials:MSPSY, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 PINES BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6422
Mailing Address - Country:US
Mailing Address - Phone:754-704-6867
Mailing Address - Fax:
Practice Address - Street 1:9050 PINES BLVD STE 305
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6422
Practice Address - Country:US
Practice Address - Phone:754-704-6867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18832101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109801900Medicaid