Provider Demographics
NPI:1811689425
Name:CLEMENTS, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CLEMENTS
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 1:5619 HARCROSS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2113
Mailing Address - Country:US
Mailing Address - Phone:323-539-0555
Mailing Address - Fax:
Practice Address - Street 1:520 S GRAND AVE STE 671
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90071-2655
Practice Address - Country:US
Practice Address - Phone:323-347-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33911103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical