Healthcare Provider Details

I. General information

NPI: 1093143430
Provider Name (Legal Business Name): ROYBAL MD CHEMICAL DEPENDENCE TREATMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 EXECUTIVE DR SUITE 225
SAN DIEGO CA
92121-3018
US

IV. Provider business mailing address

4520 EXECUTIVE DRIVE SUITE 225
SAN DIEGO CA
92121
US

V. Phone/Fax

Practice location:
  • Phone: 858-202-1822
  • Fax: 858-202-4421
Mailing address:
  • Phone: 858-202-1822
  • Fax: 858-202-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTA LYDIA ROYBAL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 858-202-1822