Provider Demographics
NPI:1578812194
Name:SANTOS, KRYSTLEBLUE BAUTISTA
Entity Type:Individual
Prefix:
First Name:KRYSTLEBLUE
Middle Name:BAUTISTA
Last Name:SANTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11334 DUNCAN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3043
Mailing Address - Country:US
Mailing Address - Phone:424-256-4353
Mailing Address - Fax:
Practice Address - Street 1:5900 S EASTERN AVE STE 142
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-4024
Practice Address - Country:US
Practice Address - Phone:323-622-2020
Practice Address - Fax:323-622-2021
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)