Provider Demographics
NPI:1053540971
Name:CHAIDEZ, CRYSTAL LAURA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LAURA
Last Name:CHAIDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E AVENIDA DE LA MERCED RM 103A
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2752
Mailing Address - Country:US
Mailing Address - Phone:323-887-5324
Mailing Address - Fax:323-887-5801
Practice Address - Street 1:215 E AVENIDA DE LA MERCED RM 103A
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2752
Practice Address - Country:US
Practice Address - Phone:323-887-5324
Practice Address - Fax:323-887-5801
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA640311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker