Healthcare Provider Details

I. General information

NPI: 1053540971
Provider Name (Legal Business Name): CRYSTAL LAURA CHAIDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E AVENIDA DE LA MERCED RM 103A
MONTEBELLO CA
90640-2752
US

IV. Provider business mailing address

215 E AVENIDA DE LA MERCED RM 103A
MONTEBELLO CA
90640-2752
US

V. Phone/Fax

Practice location:
  • Phone: 323-887-5324
  • Fax: 323-887-5801
Mailing address:
  • Phone: 323-887-5324
  • Fax: 323-887-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number64031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: