Provider Demographics
NPI:1841663093
Name:BICEGO, CRYSTAL ANTOINETTE (M S MFT INTERN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANTOINETTE
Last Name:BICEGO
Suffix:
Gender:F
Credentials:M S MFT INTERN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:BICEGO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M S MFTI
Mailing Address - Street 1:17337 VENTURA BLVD STE 327
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3967
Mailing Address - Country:US
Mailing Address - Phone:310-461-4361
Mailing Address - Fax:
Practice Address - Street 1:17337 VENTURA BLVD
Practice Address - Street 2:STE 327
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3903
Practice Address - Country:US
Practice Address - Phone:310-461-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF85211106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942234133OtherESTEE DIAMOND, MS, LMFT