Basic Information
| Provider Information | |||||||||
| NPI: | 1831715192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISOSTOMO | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | JENNIFER ANN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RADT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 E BALL RD APT 153 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928065312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493799937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 20331 FLANAGAN ROAD | ||||||||
| Address2: | |||||||||
| City: | TRABUCO CANYON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1371921119 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.