Basic Information
| Provider Information | |||||||||
| NPI: | 1578947149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLEJOS | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1481 WINDSOR DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093616470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2015 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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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 | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | Behavioral Health & Social Service Providers | Counselor | Professional | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.