Provider Demographics
NPI:1801401484
Name:GAZA, CRYSTAL ROSE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:GAZA
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 1:1710 SIGNATURE PL UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2894
Mailing Address - Country:US
Mailing Address - Phone:858-353-2515
Mailing Address - Fax:
Practice Address - Street 1:1250 MORENA BLVD FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3815
Practice Address - Country:US
Practice Address - Phone:858-353-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist