Basic Information
| Provider Information | |||||||||
| NPI: | 1104122050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Credential: | MFTT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1307 W 6TH ST | ||||||||
| Address2: | STE. 109 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928823294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512791333 | ||||||||
| FaxNumber: | 9512798333 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 W 6TH ST | ||||||||
| Address2: | STE. 109 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512791333 | ||||||||
| FaxNumber: | 9512798333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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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 | 106044 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.