Provider Demographics
NPI:1922320845
Name:KRISHTAL, ELENA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:
Last Name:KRISHTAL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1693 CARMEL CIR E
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1707
Mailing Address - Country:US
Mailing Address - Phone:909-606-5000
Mailing Address - Fax:
Practice Address - Street 1:1693 CARMEL CIR EAST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-1706
Practice Address - Country:US
Practice Address - Phone:909-606-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical