Healthcare Provider Details

I. General information

NPI: 1124391099
Provider Name (Legal Business Name): CRISTAL REGALADO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SHAKESPEARE AVE
BRONX NY
10452-1851
US

IV. Provider business mailing address

501 W 171ST ST APT 4B
NEW YORK NY
10032-3409
US

V. Phone/Fax

Practice location:
  • Phone: 718-732-7080
  • Fax:
Mailing address:
  • Phone: 646-578-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number085865-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: