Provider Demographics
NPI:1982118238
Name:AVILA, CRYSTAL MEDRANO (BI)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:MEDRANO
Last Name:AVILA
Suffix:
Gender:F
Credentials:BI
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:AVILA
Other - Last Name:MEDRANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BI
Mailing Address - Street 1:15373 INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3425
Mailing Address - Country:US
Mailing Address - Phone:858-699-7579
Mailing Address - Fax:858-726-6021
Practice Address - Street 1:15373 INNOVATION DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3425
Practice Address - Country:US
Practice Address - Phone:858-699-7579
Practice Address - Fax:858-726-6021
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-23
Last Update Date:2017-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-17-42571106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARBT-17-42571OtherRBT