MEDICARE: CRYSTAL VENEGAS LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	107055	CA
2	106H00000X	Marriage & Family Therapist	125525	CA

General Provider Information

NPI Number	:	1538520036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL VENEGAS LMFT

Provider Business Mailing Address
First Line	:	9330 BASE LINE RD STE 102
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-5827
Country	:	US
Telephone Number	:	626-696-8665
Fax Number	:

Provider Business Practice Location Address
First Line	:	9330 BASE LINE RD STE 102
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-5827
Country	:	US
Telephone Number	:	626-696-8665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2016
Last Update Date	:	05/10/2023

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