Healthcare Provider Details

I. General information

NPI: 1992485288
Provider Name (Legal Business Name): CRYSTAL DENISE VALLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6767 FOREST LAWN DR STE 100
LOS ANGELES CA
90068-1027
US

IV. Provider business mailing address

119 W TORRANCE BLVD STE 100
REDONDO BEACH CA
90277-3600
US

V. Phone/Fax

Practice location:
  • Phone: 310-374-3300
  • Fax: 310-374-3307
Mailing address:
  • Phone: 310-374-3300
  • Fax: 310-374-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: