Healthcare Provider Details

I. General information

NPI: 1578947149
Provider Name (Legal Business Name): CRYSTAL BALLEJOS APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 CARROLL CT
CHINO CA
91710-3139
US

IV. Provider business mailing address

7365 CARNELIAN ST STE 127
RANCHO CUCAMONGA CA
91730-1100
US

V. Phone/Fax

Practice location:
  • Phone: 909-581-0880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: