Provider Demographics
NPI:1962177436
Name:FERMIN, KRYSTAL ANNE FELIZMENIO (MSW)
Entity type:Individual
Prefix:
First Name:KRYSTAL ANNE
Middle Name:FELIZMENIO
Last Name:FERMIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 VALLEJO CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9070
Mailing Address - Country:US
Mailing Address - Phone:925-325-7567
Mailing Address - Fax:
Practice Address - Street 1:3200 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-7371
Practice Address - Country:US
Practice Address - Phone:213-382-1819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA1055421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker