Provider Demographics
NPI:1245664093
Name:DIAZ, KRYSTAL DESIREE
Entity type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:DESIREE
Last Name:DIAZ
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 1:4617 YELLOWSTONE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-3746
Mailing Address - Country:US
Mailing Address - Phone:323-382-4856
Mailing Address - Fax:
Practice Address - Street 1:36 S KINNELOA AVE STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3853
Practice Address - Country:US
Practice Address - Phone:323-844-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW63826101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health