Healthcare Provider Details

I. General information

NPI: 1033026851
Provider Name (Legal Business Name): CRYSTAL WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10325 STATHOS DR
ELK GROVE CA
95757-1608
US

IV. Provider business mailing address

9510 ELK GROVE FLORIN RD
ELK GROVE CA
95624-1801
US

V. Phone/Fax

Practice location:
  • Phone: 916-714-0106
  • Fax:
Mailing address:
  • Phone: 916-686-5085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: