Healthcare Provider Details

I. General information

NPI: 1790822245
Provider Name (Legal Business Name): CHRYSTAL LYNN CARLSON IMF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W GUTIERREZ ST
SANTA BARBARA CA
93101-3424
US

IV. Provider business mailing address

123 W GUTIERREZ ST
SANTA BARBARA CA
93101-3424
US

V. Phone/Fax

Practice location:
  • Phone: 805-965-1001
  • Fax:
Mailing address:
  • Phone: 805-965-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC46848
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIF43074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: