Provider Demographics
NPI:1538795034
Name:CHINOTHAI, KRYSTAL WANIDA (BA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:WANIDA
Last Name:CHINOTHAI
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7328 GOLFCREST DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1611
Mailing Address - Country:US
Mailing Address - Phone:951-440-4777
Mailing Address - Fax:
Practice Address - Street 1:662 ENCINITAS BLVD STE 208
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6789
Practice Address - Country:US
Practice Address - Phone:760-634-1125
Practice Address - Fax:760-634-1530
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician