1093838500 NPI number — MISS KRISTAL ALEXIS AUDOMA LMFT

Table of content: MISS KRISTAL ALEXIS AUDOMA LMFT (NPI 1093838500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093838500 NPI number — MISS KRISTAL ALEXIS AUDOMA LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUDOMA
Provider First Name:
KRISTAL
Provider Middle Name:
ALEXIS
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093838500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10046 FREMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTCLAIR
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91763-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-841-6853
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 ANGELES VISTA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIEW PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90043-1648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-295-4555
Provider Business Practice Location Address Fax Number:
323-508-0150
Provider Enumeration Date:
04/09/2007

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: 106H00000X , with the licence number:  50388 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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