Provider Demographics
NPI:1417285420
Name:ROSE, CRYSTAL LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LOUISE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 QUINTANA RD
Mailing Address - Street 2:# 101
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1939
Mailing Address - Country:US
Mailing Address - Phone:805-528-3421
Mailing Address - Fax:
Practice Address - Street 1:630 QUINTANA RD
Practice Address - Street 2:# 101
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1939
Practice Address - Country:US
Practice Address - Phone:805-528-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical