Healthcare Provider Details

I. General information

NPI: 1952025991
Provider Name (Legal Business Name): VANESSA CRYSTAL SALAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/10/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23701 E EAST FORK RD
AZUSA CA
91702-1477
US

IV. Provider business mailing address

23701 E EAST FORK RD
AZUSA CA
91702-1477
US

V. Phone/Fax

Practice location:
  • Phone: 626-910-1202
  • Fax:
Mailing address:
  • Phone: 626-250-3290
  • Fax: 626-910-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: