Provider Demographics
NPI:1053644013
Name:CRISOLO, CEDRIC (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:CRISOLO
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17609 VENTURA BLVD
Mailing Address - Street 2:ST. 215
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-414-9211
Mailing Address - Fax:
Practice Address - Street 1:17609 VENTURA BLVD
Practice Address - Street 2:ST. 215
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3858
Practice Address - Country:US
Practice Address - Phone:818-501-8352
Practice Address - Fax:818-501-8325
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11314656103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid