Provider Demographics
NPI:1073251575
Name:FUENTEZ, CRYSTAL (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:FUENTEZ
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2339 HILGARD AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1340
Mailing Address - Country:US
Mailing Address - Phone:916-420-8098
Mailing Address - Fax:
Practice Address - Street 1:2801 SHADELANDS DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2550
Practice Address - Country:US
Practice Address - Phone:925-794-8151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT23285225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist