Healthcare Provider Details

I. General information

NPI: 1104429323
Provider Name (Legal Business Name): CRYSTAL ANN ESPINOZA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 12/08/2021
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MONTAGUE AVE APT C
FULLERTON CA
92831-3952
US

IV. Provider business mailing address

PO BOX 7295
FULLERTON CA
92834-7295
US

V. Phone/Fax

Practice location:
  • Phone: 562-324-8421
  • Fax:
Mailing address:
  • Phone: 562-324-8421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111880
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: