Provider Demographics
NPI:1073032389
Name:FRAZIER-PHILO, KRYSTLE ROSE (EDD)
Entity Type:Individual
Prefix:DR
First Name:KRYSTLE
Middle Name:ROSE
Last Name:FRAZIER-PHILO
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:KRYSTLE
Other - Middle Name:ROSE
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD
Mailing Address - Street 1:9600 CENTER AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5838
Mailing Address - Country:US
Mailing Address - Phone:800-434-8923
Mailing Address - Fax:
Practice Address - Street 1:9600 CENTER AVE STE 160
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5838
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31885103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health