Healthcare Provider Details

I. General information

NPI: 1427310937
Provider Name (Legal Business Name): GREGORY DIEHL CRAWFORD PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 SHELBY ST STE 200
ONTARIO CA
91764-5556
US

IV. Provider business mailing address

3350 SHELBY ST STE 200
ONTARIO CA
91764-5556
US

V. Phone/Fax

Practice location:
  • Phone: 909-935-2385
  • Fax: 909-935-2685
Mailing address:
  • Phone: 909-935-2385
  • Fax: 909-935-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY28640
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY28640
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: