=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750952032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSIE CRILLY LMFT
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2021
-----------------------------------------------------
Last Update Date | 10/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3641 MT DIABLO BLVD UNIT 446
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-767-0764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3641 MT DIABLO BLVD UNIT 446
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94549-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-767-0764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT147955
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------