Healthcare Provider Details

I. General information

NPI: 1164090536
Provider Name (Legal Business Name): CASSANDRA RENEE CROOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

IV. Provider business mailing address

15217 SAN BERNARDINO AVE
FONTANA CA
92335-5327
US

V. Phone/Fax

Practice location:
  • Phone: 909-386-8510
  • Fax: 909-387-7757
Mailing address:
  • Phone: 951-643-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-7YGOKX
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: