Healthcare Provider Details

I. General information

NPI: 1013876606
Provider Name (Legal Business Name): CRYSTAL ANN PHILLIPS SUDRC-1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

IV. Provider business mailing address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

V. Phone/Fax

Practice location:
  • Phone: 619-440-4801
  • Fax:
Mailing address:
  • Phone: 619-440-4801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number23113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRCI23113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: