Healthcare Provider Details

I. General information

NPI: 1861056723
Provider Name (Legal Business Name): CRYSTAL GEORGIA MARQUEZ SUDRC9392
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 W OCEAN AVE
LOMPOC CA
93436-6630
US

IV. Provider business mailing address

604 W OCEAN AVE
LOMPOC CA
93436-6630
US

V. Phone/Fax

Practice location:
  • Phone: 805-736-0957
  • Fax: 800-696-9350
Mailing address:
  • Phone: 805-736-0357
  • Fax: 800-969-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC9392
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9392
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCADTP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: