Basic Information
| Provider Information | |||||||||
| NPI: | 1194206797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALDEZ | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | RUBY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | A.C.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 S. GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263355980 | ||||||||
| FaxNumber: | 6263355989 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 S. GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917405000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263355980 | ||||||||
| FaxNumber: | 6263355989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 11/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/04/2019 | ||||||||
| NPIReactivationDate: | 11/27/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 92448 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.