Healthcare Provider Details

I. General information

NPI: 1780170704
Provider Name (Legal Business Name): KRISTA MAE SANCHEZ TIZON RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 GRANDE WAY SUITE B
RIDGECREST CA
93555
US

IV. Provider business mailing address

123 GRANDE WAY STE B
RIDGECREST CA
93555-4182
US

V. Phone/Fax

Practice location:
  • Phone: 760-792-3089
  • Fax:
Mailing address:
  • Phone: 760-792-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-58511
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: