Healthcare Provider Details

I. General information

NPI: 1124436522
Provider Name (Legal Business Name): CRYSTAL RODRIGUES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000B S CENTER DR
CLEARLAKE CA
95422-8131
US

IV. Provider business mailing address

6302 13TH AVE
LUCERNE CA
95458
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-7090
  • Fax:
Mailing address:
  • Phone: 707-994-7090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number91708
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number91708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: