Provider Demographics
NPI:1962788620
Name:BURNS, CRYSTAL VERONICA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:VERONICA
Last Name:BURNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 559
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-0559
Mailing Address - Country:US
Mailing Address - Phone:951-386-9709
Mailing Address - Fax:951-602-6508
Practice Address - Street 1:155 W HOSPITALITY LN STE 245
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3318
Practice Address - Country:US
Practice Address - Phone:909-939-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA765781041C0700X
CA35346171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator