Provider Demographics
NPI:1649734468
Name:HERNANDEZ, CRYSTAL YVETTE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:YVETTE
Last Name:HERNANDEZ
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 1:17203 VENTURA BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4055
Mailing Address - Country:US
Mailing Address - Phone:818-501-3615
Mailing Address - Fax:
Practice Address - Street 1:17203 VENTURA BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4055
Practice Address - Country:US
Practice Address - Phone:818-501-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-18-9391103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst