Provider Demographics
NPI:1396361333
Name:BERNAL, CRYSTAL ANN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:BERNAL
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 1:5201 VENICE AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2337
Mailing Address - Country:US
Mailing Address - Phone:505-916-2007
Mailing Address - Fax:
Practice Address - Street 1:5201 VENICE AVE NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2337
Practice Address - Country:US
Practice Address - Phone:505-916-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-11506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker