Provider Demographics
NPI:1891355269
Name:EZUMAH, CHIMERE CRYSTAL
Entity type:Individual
Prefix:
First Name:CHIMERE
Middle Name:CRYSTAL
Last Name:EZUMAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 E BALL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-5157
Mailing Address - Country:US
Mailing Address - Phone:714-517-6300
Mailing Address - Fax:714-517-6306
Practice Address - Street 1:2035 E BALL RD STE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5157
Practice Address - Country:US
Practice Address - Phone:714-517-6300
Practice Address - Fax:714-517-6306
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA153398106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician