Healthcare Provider Details

I. General information

NPI: 1609336833
Provider Name (Legal Business Name): CRYSTAL UKPONG MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 EASTVIEW AVE
UPLAND CA
91784-8022
US

IV. Provider business mailing address

8780 19TH ST UNIT 398
ALTA LOMA CA
91701-4608
US

V. Phone/Fax

Practice location:
  • Phone: 888-618-2327
  • Fax: 888-918-2327
Mailing address:
  • Phone: 888-618-2327
  • Fax: 888-918-2327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: