Provider Demographics
NPI:1437525524
Name:PRUNG, CRYSTLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTLE
Middle Name:
Last Name:PRUNG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CRYSTLE
Other - Middle Name:
Other - Last Name:PRUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:7000 ROMAINE STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-7318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7000 ROMAINE ST STE 207
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-2304
Practice Address - Country:US
Practice Address - Phone:213-465-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31568103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical