Provider Demographics
NPI:1861056723
Name:MARQUEZ, CRYSTAL GEORGIA (SUDRC9392)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GEORGIA
Last Name:MARQUEZ
Suffix:
Gender:F
Credentials:SUDRC9392
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6630
Mailing Address - Country:US
Mailing Address - Phone:805-736-0357
Mailing Address - Fax:800-969-9350
Practice Address - Street 1:604 W OCEAN AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6630
Practice Address - Country:US
Practice Address - Phone:805-736-0957
Practice Address - Fax:800-696-9350
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDRC9392101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9392OtherCADTP