Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) |
NPI | 1265194740 |
---|---|
Provider Name | Crystal Pureco-Carmona |
First Address | Fresno, CA 93703-2052 |
Second Address | Fresno, CA 93703-2052 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2021 |
Last Update Date | 12/10/2021 |