Provider Demographics
NPI:1720108335
Name:KRULL, CRYSTAL ROSE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:ROSE
Last Name:KRULL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 S GRANT ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-1626
Mailing Address - Country:US
Mailing Address - Phone:916-955-9984
Mailing Address - Fax:
Practice Address - Street 1:1117 S GRANT ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-1626
Practice Address - Country:US
Practice Address - Phone:916-955-9984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CA26496103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist