Provider Demographics
NPI:1972353290
Name:LONG, CHRYSTINA (PPS, APCC)
Entity Type:Individual
Prefix:
First Name:CHRYSTINA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PPS, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 ASHPORT ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2804
Mailing Address - Country:US
Mailing Address - Phone:626-318-2186
Mailing Address - Fax:
Practice Address - Street 1:540 E FOOTHILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1251
Practice Address - Country:US
Practice Address - Phone:626-779-8583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool