Provider Demographics
NPI:1285106161
Name:FAVELA, CRYSTAL JANET (BA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JANET
Last Name:FAVELA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12141 BROOKHURST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-2865
Mailing Address - Country:US
Mailing Address - Phone:714-296-1934
Mailing Address - Fax:
Practice Address - Street 1:12141 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2865
Practice Address - Country:US
Practice Address - Phone:949-631-9045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator