Healthcare Provider Details

I. General information

NPI: 1134794647
Provider Name (Legal Business Name): LEOLA E CRISSMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31165 TEMECULA PKWY STE G3
TEMECULA CA
92592-2908
US

IV. Provider business mailing address

32962 MONTE DR
TEMECULA CA
92592-3311
US

V. Phone/Fax

Practice location:
  • Phone: 805-290-5002
  • Fax:
Mailing address:
  • Phone: 805-290-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number136432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: