=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245664093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KRYSTAL DESIREE DIAZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2013
-----------------------------------------------------
Last Update Date | 10/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 S KINNELOA AVE STE 100
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-844-3033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4617 YELLOWSTONE ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90032-3746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-382-4856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | ASW63826
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------