Provider Demographics
NPI:1447990825
Name:GRIDIRON, CRYSTAL LADONNA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LADONNA
Last Name:GRIDIRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LADONNA
Other - Last Name:GRIDIRON-OLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93613-0771
Mailing Address - Country:US
Mailing Address - Phone:559-287-2312
Mailing Address - Fax:
Practice Address - Street 1:2719 N AIR FRESNO DR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1547
Practice Address - Country:US
Practice Address - Phone:559-600-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100186101YM0800X, 104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker