Provider Demographics
NPI:1114779311
Name:HOLLOMON, KRYSTA
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:HOLLOMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25107 DORIA AVE
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-1717
Mailing Address - Country:US
Mailing Address - Phone:562-476-0108
Mailing Address - Fax:
Practice Address - Street 1:844 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1325
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)