Provider Demographics
NPI:1679182356
Name:ROSALES, CHRYSTAL
Entity Type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:
Last Name:ROSALES
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 1:6540 REFLECTION DR APT 1404
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-5142
Mailing Address - Country:US
Mailing Address - Phone:619-207-7984
Mailing Address - Fax:
Practice Address - Street 1:3994 VIA DEL BARDO
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-1524
Practice Address - Country:US
Practice Address - Phone:619-207-7984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician