Provider Demographics
NPI:1619210390
Name:BOWLBY, CRYSTAL (PHD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BOWLBY
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 1:6655 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3326
Mailing Address - Country:US
Mailing Address - Phone:562-903-4800
Mailing Address - Fax:
Practice Address - Street 1:12625 LA MIRADA BLVD
Practice Address - Street 2:202
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2211
Practice Address - Country:US
Practice Address - Phone:562-903-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23856103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY23856OtherPROFESSIONAL LICENSE