Provider Demographics
NPI:1972339190
Name:CARLSON, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:CARLSON
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 1:2020 IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0520
Mailing Address - Country:US
Mailing Address - Phone:951-580-1022
Mailing Address - Fax:
Practice Address - Street 1:2020 IOWA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0520
Practice Address - Country:US
Practice Address - Phone:951-580-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator