Healthcare Provider Details

I. General information

NPI: 1356973788
Provider Name (Legal Business Name): EMMA REBECCA CRISSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14632 YORBA ST
TUSTIN CA
92780-2554
US

IV. Provider business mailing address

980 CATALINA
LAGUNA BEACH CA
92651-2748
US

V. Phone/Fax

Practice location:
  • Phone: 714-714-0780
  • Fax:
Mailing address:
  • Phone: 949-494-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: