Healthcare Provider Details

I. General information

NPI: 1467018580
Provider Name (Legal Business Name): CRYSTAL VILLA HERNANDEZ ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41689 ENTERPRISE CIR N STE 120
TEMECULA CA
92590-5630
US

IV. Provider business mailing address

29768 DAWNCREST CIR
TEMECULA CA
92591-1878
US

V. Phone/Fax

Practice location:
  • Phone: 951-587-4165
  • Fax:
Mailing address:
  • Phone: 760-682-8076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: