Healthcare Provider Details

I. General information

NPI: 1245664093
Provider Name (Legal Business Name): MS. KRYSTAL DESIREE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 S KINNELOA AVE STE 100
PASADENA CA
91107-3853
US

IV. Provider business mailing address

4617 YELLOWSTONE ST
LOS ANGELES CA
90032-3746
US

V. Phone/Fax

Practice location:
  • Phone: 323-844-3033
  • Fax:
Mailing address:
  • Phone: 323-382-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW63826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: