Basic Information
| Provider Information | |||||||||
| NPI: | 1023691615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISOSTOMO | ||||||||
| FirstName: | YACENIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 N 16TH ST STE 316 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850061266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026501212 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1305 TACOMA AVE S STE 201 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533965823 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2021 | ||||||||
| LastUpdateDate: | 05/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | SC61155013 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.