Provider Demographics
NPI:1679141410
Name:JUSTICE, CRYSTINA ROSE
Entity Type:Individual
Prefix:
First Name:CRYSTINA
Middle Name:ROSE
Last Name:JUSTICE
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 1:31470 AVENIDA JUAREZ
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3011
Mailing Address - Country:US
Mailing Address - Phone:760-408-0426
Mailing Address - Fax:
Practice Address - Street 1:31470 AVENIDA JUAREZ
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3011
Practice Address - Country:US
Practice Address - Phone:760-408-0426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty