Provider Demographics
NPI:1396879045
Name:BOARD, KRYSTAL R
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:R
Last Name:BOARD
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 1:7223 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-4964
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:
Practice Address - Street 1:7223 FAIR AVE
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-4964
Practice Address - Country:US
Practice Address - Phone:818-898-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40199106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist