MEDICARE: CRYSTAL GEORGIA MARQUEZ SUDCC #9392

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	SUDRC9392	CA
2	175T00000X	Peer Specialist	MPPSS-HBGDEZ	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9392	OTHER	CA	CADTP

General Provider Information

NPI Number	:	1861056723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL GEORGIA MARQUEZ SUDCC #9392

Provider Business Mailing Address
First Line	:	1401 E MAIN ST
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93454-4801
Country	:	US
Telephone Number	:	805-930-1550
Fax Number	:	805-957-5902

Provider Business Practice Location Address
First Line	:	1401 E MAIN ST
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93454-4801
Country	:	US
Telephone Number	:	805-930-1550
Fax Number	:	805-957-5902

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	01/29/2026

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Directions to “ CRYSTAL GEORGIA MARQUEZ SUDCC #9392” Practice Location

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