Healthcare Provider Details

I. General information

NPI: 1093076473
Provider Name (Legal Business Name): KC CRAWFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 MISSION GORGE RD
SAN DIEGO CA
92120-1130
US

IV. Provider business mailing address

7410 MISSION VALLEY RD
SAN DIEGO CA
92108-4405
US

V. Phone/Fax

Practice location:
  • Phone: 858-300-0460
  • Fax: 858-300-0461
Mailing address:
  • Phone: 619-497-8989
  • Fax: 858-552-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number74680
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: