Provider Demographics
NPI:1811612831
Name:SIAFEGA, CRYSTAL CARLEEN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CARLEEN
Last Name:SIAFEGA
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 1:2329 PURDUE DR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-6365
Mailing Address - Country:US
Mailing Address - Phone:562-446-5222
Mailing Address - Fax:
Practice Address - Street 1:2329 PURDUE DR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6365
Practice Address - Country:US
Practice Address - Phone:562-446-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE