Provider Demographics
NPI:1528562485
Name:STAFFORD, CRYSTENA NICOLE
Entity Type:Individual
Prefix:
First Name:CRYSTENA
Middle Name:NICOLE
Last Name:STAFFORD
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 1:4221 WILSHIRE BLVD STE 300A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 UNIVERSITY AVE STE 175
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician