Provider Demographics
NPI:1093180101
Name:DEWITT, KRISTINE (LMFT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY STE 11B
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4341
Mailing Address - Country:US
Mailing Address - Phone:209-550-5850
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY VILLAGE WAY STE 11B
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4341
Practice Address - Country:US
Practice Address - Phone:209-550-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist