Healthcare Provider Details

I. General information

NPI: 1528612314
Provider Name (Legal Business Name): CRISTINA THI TRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8620 PAGODA WAY
SAN DIEGO CA
92126-3615
US

IV. Provider business mailing address

8620 PAGODA WAY
SAN DIEGO CA
92126-3615
US

V. Phone/Fax

Practice location:
  • Phone: 619-721-4057
  • Fax:
Mailing address:
  • Phone: 619-721-4057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: