Provider Demographics
NPI:1275175200
Name:KHA, CRYSTAL QUE (MED)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:QUE
Last Name:KHA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W 48TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-6960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1230 ROSECRANS AVE STE 250
Practice Address - Street 2:
Practice Address - City:MANHATTAN BCH
Practice Address - State:CA
Practice Address - Zip Code:90266-2496
Practice Address - Country:US
Practice Address - Phone:310-406-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst