Provider Demographics
NPI:1124369244
Name:ROUDEBUSH, KRISTEN VIRGINIA (LMFT)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:VIRGINIA
Last Name:ROUDEBUSH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KRIS
Other - Middle Name:
Other - Last Name:ROUDEBUSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:2050 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5203
Mailing Address - Country:US
Mailing Address - Phone:805-441-3845
Mailing Address - Fax:
Practice Address - Street 1:2050 BROAD ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5203
Practice Address - Country:US
Practice Address - Phone:805-441-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107108106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist