1437585296 NPI number — KRISTINA ELISE IRESON LCSW 80918

Table of content: KRISTINA ELISE IRESON LCSW 80918 (NPI 1437585296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437585296 NPI number — KRISTINA ELISE IRESON LCSW 80918

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRESON
Provider First Name:
KRISTINA
Provider Middle Name:
ELISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW 80918
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAMOTA
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437585296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 661
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PACIFICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94044-0661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-832-6900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
957 INDUSTRIAL RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN CARLOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94070-4152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-832-6900
Provider Business Practice Location Address Fax Number:
650-620-9549
Provider Enumeration Date:
09/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041S0200X , with the licence number:  PPS , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 80918 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: 80918 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)