Basic Information
| Provider Information | |||||||||
| NPI: | 1285198093 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | KRYSTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 S MYRTLE AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910163406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516868500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 TECHNOLOGY CT STE 300 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516868500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2019 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106S00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.