Provider Demographics
NPI:1083072722
Name:PHILLIPS-MATSON, KRISTIN A (LPCC)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:A
Last Name:PHILLIPS-MATSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2937
Mailing Address - Country:US
Mailing Address - Phone:831-325-9168
Mailing Address - Fax:
Practice Address - Street 1:100 W EL CAMINO REAL
Practice Address - Street 2:SUITE 74B
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2664
Practice Address - Country:US
Practice Address - Phone:831-325-9168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663101YM0800X, 101YP2500X, 103K00000X
CA130139844101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst