Healthcare Provider Details

I. General information

NPI: 1912645367
Provider Name (Legal Business Name): CRYSTAL DUARTE ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 E 17TH ST STE 101
SANTA ANA CA
92701-2641
US

IV. Provider business mailing address

5196 GENEVIEVE ST
SAN BERNARDINO CA
92407-3212
US

V. Phone/Fax

Practice location:
  • Phone: 714-352-2911
  • Fax:
Mailing address:
  • Phone: 909-648-2576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number102503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: