MEDICARE: MS. CRYSTAL ELEXUS WASHINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1053043158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CRYSTAL ELEXUS WASHINGTON

Provider Business Mailing Address
First Line	:	204 W LOS ANGELES DR
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-3101
Country	:	US
Telephone Number	:	336-728-5462
Fax Number	:

Provider Business Practice Location Address
First Line	:	2204 S EL CAMINO REAL STE 220
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-6376
Country	:	US
Telephone Number	:	336-728-5642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2022
Last Update Date	:	02/20/2025

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