Healthcare Provider Details

I. General information

NPI: 1447993100
Provider Name (Legal Business Name): CRYSTALYN AYLEEN DELA CRUZ AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 E GISH RD
SAN JOSE CA
95112-4706
US

IV. Provider business mailing address

232 E GISH RD
SAN JOSE CA
95112-4706
US

V. Phone/Fax

Practice location:
  • Phone: 669-308-7384
  • Fax:
Mailing address:
  • Phone: 669-308-7384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142286
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: