Provider Demographics
NPI:1790377067
Name:BETTENHAUSEN-BUBULKA, CRYSTAL MARIE (HI LCSW 4606)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:BETTENHAUSEN-BUBULKA
Suffix:
Gender:F
Credentials:HI LCSW 4606
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:BETTENHAUSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HI LCSW 4606
Mailing Address - Street 1:941 ORANGE AVE # 536
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-2609
Mailing Address - Country:US
Mailing Address - Phone:808-319-7896
Mailing Address - Fax:
Practice Address - Street 1:1050 KETTNER BLVD STE D
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3339
Practice Address - Country:US
Practice Address - Phone:808-319-7896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI46061041C0700X
CALCSW1006391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical