Provider Demographics
NPI:1164041687
Name:CRUMB, HALLEY IRENE (ADULT RESIDENTIAL)
Entity Type:Individual
Prefix:MS
First Name:HALLEY
Middle Name:IRENE
Last Name:CRUMB
Suffix:
Gender:F
Credentials:ADULT RESIDENTIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 JOSEPH AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6259
Mailing Address - Country:US
Mailing Address - Phone:650-461-0433
Mailing Address - Fax:
Practice Address - Street 1:16236 N LAKE ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-1615
Practice Address - Country:US
Practice Address - Phone:650-461-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60315007353747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6031500735OtherCOMMUNITY CARE LICENSE DIVISION