Provider Demographics
NPI:1174033518
Name:PEDERSON, KRISTA (CADC)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-4472
Mailing Address - Country:US
Mailing Address - Phone:515-414-8059
Mailing Address - Fax:515-209-7081
Practice Address - Street 1:1211 VINE ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-4472
Practice Address - Country:US
Practice Address - Phone:515-414-8059
Practice Address - Fax:515-209-7081
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16028101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)