Provider Demographics
NPI:1275329070
Name:FAN, CRYSTAL L
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:FAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1075 CREEKSIDE RIDGE DR STE 280
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-3504
Mailing Address - Country:US
Mailing Address - Phone:510-993-9963
Mailing Address - Fax:
Practice Address - Street 1:3173 ORWELL PL
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3537
Practice Address - Country:US
Practice Address - Phone:510-993-9963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician