Healthcare Provider Details

I. General information

NPI: 1730734658
Provider Name (Legal Business Name): CRYSTAL R THORNTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N B ST STE E
SACRAMENTO CA
95811-0326
US

IV. Provider business mailing address

1103 N B ST STE E
SACRAMENTO CA
95811-0326
US

V. Phone/Fax

Practice location:
  • Phone: 510-306-5660
  • Fax:
Mailing address:
  • Phone: 510-306-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: