Provider Demographics
NPI:1285929984
Name:CROWE, KRISTEN KERRY
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KERRY
Last Name:CROWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:KERRY
Other - Last Name:NIEDERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1509 OBISPO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-1724
Mailing Address - Country:US
Mailing Address - Phone:714-614-6574
Mailing Address - Fax:
Practice Address - Street 1:2904 W SUNSET BLVD STE 6
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7308
Practice Address - Country:US
Practice Address - Phone:213-259-3793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5451101YM0800X
CA1267225600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5451OtherBOARD OF BEHAVIORAL SCIENCE