Provider Demographics
NPI:1962661165
Name:CRISOSTOMO, FATIMA SUSANA (BA)
Entity Type:Individual
Prefix:MISS
First Name:FATIMA
Middle Name:SUSANA
Last Name:CRISOSTOMO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W BAYLESS ST
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-3424
Mailing Address - Country:US
Mailing Address - Phone:626-334-8482
Mailing Address - Fax:
Practice Address - Street 1:2555 E COLORADO BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-6622
Practice Address - Country:US
Practice Address - Phone:626-577-2261
Practice Address - Fax:626-577-2543
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN809OtherLA COUNTY DMH