Provider Demographics
NPI:1740054519
Name:HARRIS, KRYSTLE M
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:M
Last Name:HARRIS
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 1:3575 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3413
Mailing Address - Country:US
Mailing Address - Phone:619-294-4526
Mailing Address - Fax:833-341-1107
Practice Address - Street 1:3575 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3413
Practice Address - Country:US
Practice Address - Phone:619-294-4526
Practice Address - Fax:833-341-1107
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1522950823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)