Healthcare Provider Details

I. General information

NPI: 1760170138
Provider Name (Legal Business Name): CRYSTAL MARQUEZ RIOS ASW114226
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4296
US

IV. Provider business mailing address

606 SHELLEY ST
SANTA ANA CA
92703-4224
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax:
Mailing address:
  • Phone: 714-913-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW114226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: