Provider Demographics
NPI:1962378109
Name:CRUMBO, JUSTIN MATTHEW
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:CRUMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27990 SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-9155
Mailing Address - Country:US
Mailing Address - Phone:951-309-9135
Mailing Address - Fax:
Practice Address - Street 1:27990 SHERMAN RD
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92585-9155
Practice Address - Country:US
Practice Address - Phone:951-309-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-15
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00023096106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40000158238300Medicaid