Healthcare Provider Details

I. General information

NPI: 1700526167
Provider Name (Legal Business Name): CRYSTAL BICEGO THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 03/31/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6458 FIRMAMENT AVE
VAN NUYS CA
91406-6218
US

IV. Provider business mailing address

6458 FIRMAMENT AVE
VAN NUYS CA
91406-6218
US

V. Phone/Fax

Practice location:
  • Phone: 831-601-6341
  • Fax:
Mailing address:
  • Phone: 831-601-6341
  • Fax:

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: CRYSTAL BICEGO
Title or Position: PRESIDENT
Credential: LMFT
Phone: 831-601-6341