Provider Demographics
NPI:1568132868
Name:MCCLAIN, CRYSTAL ROSE (PHD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 ALPINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 ALPINE BLVD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-2113
Practice Address - Country:US
Practice Address - Phone:619-445-2644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
101YM0800X, 390200000X
CA94027722103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program