Provider Demographics
NPI:1376964478
Name:KIRBY, CHRYSANTHIA
Entity type:Individual
Prefix:
First Name:CHRYSANTHIA
Middle Name:
Last Name:KIRBY
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:PO BOX 2161
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92406-2161
Mailing Address - Country:US
Mailing Address - Phone:909-806-9890
Mailing Address - Fax:
Practice Address - Street 1:1430 E COOLEY DR STE 115
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3936
Practice Address - Country:US
Practice Address - Phone:909-533-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2538891041C0700X
CAVN268792164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No164X00000XNursing Service ProvidersLicensed Vocational Nurse