Healthcare Provider Details

I. General information

NPI: 1073214532
Provider Name (Legal Business Name): PHILLIP KRULISKY RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 BRENTWOOD DR
GRASS VALLEY CA
95945-5703
US

IV. Provider business mailing address

PO BOX 6021
AUBURN CA
95604-6021
US

V. Phone/Fax

Practice location:
  • Phone: 530-878-5166
  • Fax:
Mailing address:
  • Phone: 530-878-5166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1500000323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: