Healthcare Provider Details

I. General information

NPI: 1649749037
Provider Name (Legal Business Name): CRYSTAL TEANA BRYANT-SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 RALSTON ST FL 2
VENTURA CA
93003-5908
US

IV. Provider business mailing address

5810 RALSTON ST FL 2
VENTURA CA
93003-5908
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-7033
  • Fax: 805-642-7732
Mailing address:
  • Phone: 805-642-7033
  • Fax: 805-642-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: