Healthcare Provider Details

I. General information

NPI: 1104577394
Provider Name (Legal Business Name): KRYSTLE IDA RAMIREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date: 05/06/2026
Reactivation Date: 07/22/2026

III. Provider practice location address

790 E BONITA AVE
POMONA CA
91767-1906
US

IV. Provider business mailing address

1277 E KINGSLEY AVE
POMONA CA
91767-5101
US

V. Phone/Fax

Practice location:
  • Phone: 909-625-7207
  • Fax:
Mailing address:
  • Phone: 626-224-3985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW138328
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW105085
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: