Basic Information
| Provider Information | |||||||||
| NPI: | 1073143251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAWFORD | ||||||||
| FirstName: | BREANE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MESSA | ||||||||
| OtherFirstName: | BREANE | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1987 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95619 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4250 FOWLER LN STE 204 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956199782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306263105 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2020 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.