1841663093 NPI number — CRYSTAL ANTOINETTE BICEGO M. S. MFT INTERN

Table of content: CRYSTAL ANTOINETTE BICEGO M. S. MFT INTERN (NPI 1841663093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841663093 NPI number — CRYSTAL ANTOINETTE BICEGO M. S. MFT INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BICEGO
Provider First Name:
CRYSTAL
Provider Middle Name:
ANTOINETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M. S. MFT INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BICEGO
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M. S. MFTI
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1841663093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17337 VENTURA BLVD STE 327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91316-3967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-461-4361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17337 VENTURA BLVD
Provider Second Line Business Practice Location Address:
STE 327
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-461-4361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  IMF85211 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1942234133 . This is a "ESTEE DIAMOND, MS, LMFT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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