=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346954104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL DAWN FAMILY THERAPY, PROF. CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2023
-----------------------------------------------------
Last Update Date | 10/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16530 VENTURA BLVD STE 400
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-207-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10209 LURLINE AVE UNIT C
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-7730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-207-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | CRISTAL CUNNINGHAM
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 323-207-5404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------