Provider Demographics
NPI:1073214532
Name:KRULISKY, PHILLIP (RADT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:KRULISKY
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6021
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95604-6021
Mailing Address - Country:US
Mailing Address - Phone:530-878-5166
Mailing Address - Fax:
Practice Address - Street 1:159 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5703
Practice Address - Country:US
Practice Address - Phone:530-878-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1500000323101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)