Healthcare Provider Details

I. General information

NPI: 1972339190
Provider Name (Legal Business Name): KRYSTAL CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 IOWA AVE
RIVERSIDE CA
92507-0520
US

IV. Provider business mailing address

2020 IOWA AVE
RIVERSIDE CA
92507-0520
US

V. Phone/Fax

Practice location:
  • Phone: 951-580-1026
  • Fax:
Mailing address:
  • Phone: 951-580-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC23027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: