Provider Demographics
NPI:1225311863
Name:RONCANCIO, CRYSTAL SHAUNA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SHAUNA
Last Name:RONCANCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 CANAL ST APT 9
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4365
Mailing Address - Country:US
Mailing Address - Phone:415-259-1479
Mailing Address - Fax:
Practice Address - Street 1:900 5TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2928
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health