Provider Demographics
NPI:1346954104
Name:CRYSTAL DAWN FAMILY THERAPY, PROF. CORP.
Entity Type:Organization
Organization Name:CRYSTAL DAWN FAMILY THERAPY, PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:323-207-5404
Mailing Address - Street 1:10209 LURLINE AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-7730
Mailing Address - Country:US
Mailing Address - Phone:323-207-5404
Mailing Address - Fax:
Practice Address - Street 1:16530 VENTURA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4551
Practice Address - Country:US
Practice Address - Phone:323-207-5404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-06
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty