Provider Demographics
NPI:1003378647
Name:PETERSON, KRISTINA (MFT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 FREMONT AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5602
Mailing Address - Country:US
Mailing Address - Phone:650-906-0613
Mailing Address - Fax:
Practice Address - Street 1:851 FREMONT AVE STE 103
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5602
Practice Address - Country:US
Practice Address - Phone:650-906-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT45022106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist