Basic Information
| Provider Information | |||||||||
| NPI: | 1104135185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROSBY | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269671667 | ||||||||
| FaxNumber: | 6269676027 | ||||||||
| Practice Location | |||||||||
| Address1: | 1126 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269671667 | ||||||||
| FaxNumber: | 6269676027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | IMF 64617 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7439A | 05 | CA | MEDICAID | 7544 | 05 | CA | MEDICAID |